Natinal Hspital Inpatient Quality Reprting Measures Specificatins Manual Release Ntes Fr Manual Versin: 5.5 Cmpleted: June 14, 2018 Guidelines fr Using Release Ntes The Release Ntes prvides mdificatins t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures, Versin 5.5. The infrmatin in this dcument is t be used as a reference and is nt intended t be used t prgram abstractin tls. Please refer t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures fr the cmplete and current technical specificatins and abstractin infrmatin. The ntes are rganized t fllw the rder f the Table f Cntents. The implementatin date is 01/01/2019, unless therwise specified. The headings are described belw: Impacts - used t identify the impacted measures and prtin(s) f the Manual Sectin, e.g., Alphabetical Data Dictinary, Measure Infrmatin Frm (MIF) and Flwchart (Algrithm). Descriptin f Changes - used t identify the sectin within the dcument where the change ccurs, e.g., Definitin, Data Cllectin Questin, Allwable Values, and Denminatr Statement - Data Elements. Ratinale - prvided fr the change being made. Data elements that crss multiple measures and cntain the same changes will be cnslidated. NOTE: In additin t being called ut specifically in the Release Ntes dcument, additins are yellw highlighted in the crrespnding dcuments. The changes in the Hspital Initial Patient Ppulatin and Clinical Data XML File Layuts have yellw highlighted cells with actual changes nted in bld fnt.
Table f Cntents Nte: click n any sectin title in the Release Ntes t return t Table f Cntents page. Table f Cntents (n updates)... 2 Acknwledgement (n updates)... 2 Intrductin... 2 Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates)... 2 SECTION 1 Data Dictinary... 2 Intrductin t Data Dictinary... 2 Alphabetical Data Dictinary... 2 SECTION 2 Measurement Infrmatin... 37 Subsectin 2.1 Severe Sepsis and Septic Shck (SEP)... 37 Subsectin 2.2 Venus Thrmbemblism (VTE) (n updates)... 39 Subsectin 2.4 Glbal Initial Patient Ppulatin (ED, IMM, TOB, SUB) (n updates)... 39 Subsectin 2.5 Emergency Department (ED) (n updates)... 39 Subsectin 2.6 - Preventin... 39 2.6.1 - Immunizatin (IMM)... 39 2.6.2 - Substance Use (SUB) (n updates)... 39 2.6.3 - Tbacc Treatment (TOB)... 39 SECTION 3 Missing and Invalid Data... 39 SECTION 4 Ppulatin and Sampling Specificatins (n updates)... 39 SECTION 9 Data Transmissin... 40 Transmissin Overview (n updates)... 40 Transmissin Alphabetical Data Dictinary (n updates)... 40 Hspital Clinical Data XML File Layut... 40 Hspital Initial Patient Ppulatin Data XML File Layut (n updates)... 41 SECTION 10 CMS Outcme/Structural Measures... 41 Subsectin 10.1 CMS Outcme Measures (n updates)... 41 Subsectin 10.2 Structural Measures (n updates)... 41 APPENDICES... 42 Appendix A ICD-10 Cde Tables (Wrd and Excel) (n updates)... 42 Appendix C Medicatin Tables (Wrd and Excel)... 42 Appendix D Glssary f Terms (n updates)... 45 Appendix E Overview f Measure Infrmatin Frm and Flwchart Frmats (n updates)... 45 Appendix F Measure Name Crsswalk (n updates)... 45 Appendix G Resurces (n updates)... 45 Appendix H Miscellaneus Tables (n updates)... 45 Appendix P Preview Sectin (n updates)... 45 Specificatins Manual fr Hspital Inpatient Quality Measures Page 1
The cntent belw is rganized t fllw the Table f Cntents in the specificatins manual. Table f Cntents (n updates) Acknwledgement (n updates) Intrductin All Sectins Ratinale: An update is being made t reflect the current CMS and Jint Cmmissin quality initiatives related t the inpatient specificatins manual. Change Intrductin sectin thrughut. Refer t manual fr cntent edits. Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates) SECTION 1 Data Dictinary Intrductin t Data Dictinary Medical Recrd Dcumentatin Ratinale: An update is being made t reflect current manual specificatins. Change under fifth paragraph, secnd bullet pint: ICU Admissin r Transfer Date T: Septic Shck Presentatin Date Diagnstic/Labratry Tests Ratinale: An update is being made t reflect current manual specificatins. Change in secnd bullet pint: Lipid prfile T: Lactate Level Alphabetical Data Dictinary Administrative Cntraindicatin t Care, Septic Shck Ratinale: The data element is being updated t prvide additinal guidance t the abstractr. Ntes fr Abstractin Add new fifth and sixth bullet pints: An authrized patient advcate is smene (defined by facility plicy) wh is authrized t make decisins n behalf f the patient when the patient is nt able t. Specificatins Manual fr Hspital Inpatient Quality Measures Page 2
If there is a signed AMA frm r dcumentatin by a physician/apn/pa r nurse indicating the patient left AMA prir t r within 6 hurs fllwing presentatin f septic shck, select Value "1." Explicit left against medical advice dcumentatin is nt required. Patient is refusing t stay fr cntinued care select Value 1. Dcumentatin suggesting that the patient left befre discharge instructins culd be given des nt cunt as leaving against medical advice. An AMA frm signed by the patient is nt required, fr the purpses f this data element. D nt cnsider AMA dcumentatin and ther dispsitin dcumentatin as cntradictry. If any surce states the patient left against medical advice, select Value 1, regardless f whether the AMA dcumentatin was written last. AMA frm signed and discharge instructin sheet states Discharged hme with belngings select Value 1. Administrative Cntraindicatin t Care, Severe Sepsis Ratinale: The data element is being updated t prvide additinal guidance t the abstractr. Ntes fr Abstractin Add fifth and sixth bullet pints: An authrized patient advcate is smene (defined by facility plicy) wh is authrized t make decisins n behalf f the patient when the patient is nt able t. If there is a signed AMA frm r dcumentatin by a physician/apn/pa r nurse indicating the patient left AMA prir t r within 6 hurs fllwing presentatin f severe sepsis, select Value "1." Explicit left against medical advice dcumentatin is nt required. Patient is refusing t stay fr cntinued care select Value 1. Dcumentatin suggesting that the patient left befre discharge instructins culd be given des nt cunt as leaving against medical advice. An AMA frm signed by the patient is nt required, fr the purpses f this data element. D nt cnsider AMA dcumentatin and ther dispsitin dcumentatin as cntradictry. If any surce states the patient left against medical advice, select Value 1, regardless f whether the AMA dcumentatin was written last. AMA frm signed and discharge instructin sheet states Discharged hme with belngings select Value 1. Specificatins Manual fr Hspital Inpatient Quality Measures Page 3
Alchl Use Status Ratinale: The data element is being updated t prvide clarificatin fr abstractin f screening fr alchl use status utilizing a validated screening tl. Ntes fr Abstractin Add under fifth bullet pint: EXCEPTION: If there is dcumentatin f a validated questinnaire fr alchl screening cmpleted within the first day f admissin, select the apprpriate Value 1 r 2 regardless f cnflicting dcumentatin. Alchl Use Status Ratinale: The data element is being updated t prvide clarificatin fr abstractin f cgnitive impairment. Ntes fr Abstractin Remve eighth bullet pint: If there is dcumentatin that the patient has temprary cgnitive impairment due t acute substance use (e.g., verdse r acute intxicatin), Value 7 cannt be selected. Remve tenth bullet pint: If there is dcumentatin that the patient was intubated n the day f admissin (Day 0) and remains intubated thrugh the entire first day (Day 1), select allwable Value 7 as the patient is unable t answer. Change sub-bullets under twelfth bullet pint t: Examples f cgnitive impairment include: Altered Level f Cnsciusness (LOC) Altered Mental Status Cgnitive impairment Cgnitively impaired Cgnitive impairment due t acute substance use, verdse, acute intxicatin Cnfused Dementia Intubatin Memry lss Mentally handicapped Obtunded Psychtic/psychsis with dcumented symptms Sedatin Specificatins Manual fr Hspital Inpatient Quality Measures Page 4
Bld Culture Cllectin Acceptable Delay Ratinale: The data element is being updated t reduce abstractr burden and prvide clarity. Ntes fr Abstractin Change t: Only the fllwing situatins demnstrate an acceptable delay where the bld culture was drawn after the Brad Spectrum r Other Antibitic Administratin Date and Time. If there is an acceptable delay, chse Value 1. Surgical patients wh receive a pre-p r pst-p prphylactic antibitic within 24 hurs befre severe sepsis was identified and had a bld culture drawn after the prphylactic antibitic was started. Antibitics were started in the hspital fr an infectin within 24 hurs befre severe sepsis was identified, and a bld culture was drawn smetime after the antibitic dse was started. Antibitics were started prir t hspital arrival within 24 hurs befre severe sepsis was identified, and a bld culture was drawn after the pre-hspital antibitics were started. A physician/apn/pa dcumented reasn fr the delay, which makes it clear that waiting t start the antibitic wuld be detrimental t the patient. Examples: ED Physician Nte: Patient cnditin wrsening, IV Vanc rdered stat, bld and urine cultures rdered, awaiting CXR. Hspitalist Prgress Nte: Patient s deterirating cnditin cncern fr rapidly advancing infectin, starting IV antibitics nw, lab n way t cllect bld cultures. Obstetric patients given prphylactic antibitics fr ruptured membranes, grup B strep, r prir t a caesarean sectin. If there is n dcumentatin supprting an acceptable delay in the cllectin f a bld culture, chse Value 2. Exclusin Guidelines fr Abstractin Change t: Oral (PO) Antibitics Brad Spectrum r Other Antibitic Administratin Ratinale: The data element is being updated t reduce abstractr burden and prvide clarity. Ntes fr abstractin Remve sixth bullet pint: D nt cllect antibitics dcumented n an perative reprt unless the surgen states that the surgen actually administered the dse. Specificatins Manual fr Hspital Inpatient Quality Measures Page 5
Change ninth bullet pint t: D nt abstract antibitics frm surces that d nt represent actual administratin. Examples that d nt represent actual administratin: Pre-Op Checklist states: IV Started at 1730 Prep Antibitic Given at 1800 Operative reprt states: IV antibitics were given prir t prcedure IV antibitics given at 0900 prir t incisin Crystallid Fluid Administratin Ratinale: The data element is being updated t prvide additinal guidance t the abstractr. Definitin Change t: Dcumentatin f initiatin f crystallid fluids within the specified time frame AND cmplete infusin f the target rdered vlume. Suggested Data Cllectin Questin Change frm: Were crystallid fluids inititated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r physician/apn/pa Dcumentatin f Septic Shck? Change t: Were crystallid fluids initiated within the specified time frame AND cmpletely infused based n the target rdered vlume? Allwable Values Change frm: 1 (Yes) Target rdered vlume f crystallid fluids were rdered initiated, and infused prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck. 2 (N) Less than the target rdered vlume f crystallid fluids were rdered initiated, r infused prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine vlume rdered. 3 (N) Crystallid fluids were nt initiated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine whether r nt they were administered. 4 (N) There is dcumentatin the patient has an implanted Ventricular Assist Device (VAD) r dcumentatin f the patient r authrized patient advcate refusal f IV fluids. Change t: 1 (Yes) Target vlume f crystallid fluids were rdered AND initiated within the specified time frame. Additinally, the target rdered vlume was cmpletely infused. Specificatins Manual fr Hspital Inpatient Quality Measures Page 6
2 (N) Less than the target vlume f crystallid fluids were rdered OR initiated within the specified time frame. The target rdered vlume was nt cmpletely infused. 3 (N) The target vlume f crystallid fluids was NOT initiated within the specified time frame. 4 (N) There is dcumentatin the patient has an implanted Ventricular Assist Device (VAD) OR dcumentatin f the patient r authrized patient advcate refusal f IV fluids. Ntes fr Abstractin Change t: The specified time frame fr abstractin f crystallid fluids is within 6 hurs prir thrugh 3 hurs after either f the fllwing trigger events. If bth are present the specified time frame is determined by the earliest trigger. Initial Hyptensin Date and Time Septic Shck Presentatin Date and Time The target rdered vlume must be rdered and initiated within the specified time frame if Initial Hyptensin r Septic Shck is present. Additinally, in rder t chse Value 1, the target rdered vlume must be dcumented as cmpletely infused. The target rdered vlume is NOT required t be cmpletely infused within the specified time frame. If the target rdered vlume is nt cmpletely infused, chse Value 2. Crystallid fluid vlumes rdered that are equivalent t 30 ml/kg r within 10% less than 30 ml/kg are cnsidered the target rdered vlume. 2000 ml f nrmal saline was rdered and initiated in the ED. The patient s weight is nt available r dcumented at the time f the rder. After admissin t critical care a weight is btained f 74 kg. Based n this weight 30 ml/kg is 2220 ml. The 2000 ml rdered is within 10% lwer f 2220 ml (2220 ml 222 ml = 1998 ml) and is an acceptable vlume. T determine the target rdered vlume: Use the patient weight in kilgrams (kg) if dcumented. If nt dcumented, divide the weight in punds by 2.2; that yields the weight in kg. Rund the weight t the nearest whle number. Multiply the weight in kg by 30; the result is the number f ml f IV fluid that shuld be specified in the physician/apn/pa rder(s). Rund the vlume f IV fluid (ml) t the nearest whle number. Examples: Patient weight is 160 punds. 160/2.2 = 72.72 kg. Rund t 73 kg. 73 x 30 = 2190 (ml). Physician rder is Infuse 2400 ml 0.9% Nrmal Saline ver the next tw hurs. This is acceptable because 2400 ml is greater than 2190. Patient weight is 160 punds. 160/2.2 = 72.72 kg. Rund t 73 kg. 73 x 30 = 2190 (ml). Physician rder is Give 1000 ml Lactated Ringers ver the next 4 hurs. This is nt acceptable because 1000 ml is less than 2190. T calculate the apprpriate target rdered vlume use the actual r estimated weight in the fllwing pririty rder. 1. Weight dcumented in the crystallid fluid rder Specificatins Manual fr Hspital Inpatient Quality Measures Page 7
2. Weight dcumented clsest and prir t the rder fr crystallid fluids 3. Weight dcumented clsest and after the rder fr crystallid fluids Physician/APN/PA can use Ideal Bdy Weight (IBW) t determine the target rdered vlume if all f the fllwing cnditins are met: Physician/APN/PA dcuments the patient is bese (defined BMI >30). Physician/APN/PA dcuments IBW is used t determine target rdered vlume. IBW must be present in the medical recrd, abstractrs shuld nt calculate the IBW. Other acceptable weight terms include predicted weight, dsing weight, and adjusted bdy weight. If the ttal vlume f crystallid fluids rdered is less than the target rdered vlume, select Value 2. If there is dcumentatin the infusin was stpped prir t reaching the target rdered vlume, select Value 2. Dcumentatin f fluid initiatin: Medical recrd dcumentatin must be clear that crystallid fluids were actually initiated (i.e., date and time f administratin is nted). D nt use physician/apn/pa rders as equivalent t actual initiatin f fluids as they are nt specific t initiatin. Crystallid fluid rders: Physician/APN/PA rders are required fr the fluids. The rder must include the type f fluid, the vlume f fluid, and a rate r time ver which the fluids are t be given. The terms blus, wide-pen, r pen are acceptable fr a rate r infusin duratin. If the type f fluid, vlume f fluid, rate r infusin duratin is missing, d nt use the rder tward the target rdered vlume. The target rdered vlume may be in a single rder r a series f multiple rders. If crystallid fluids are initiated via multiple physician/apn/pa rders, nly abstract crystallid fluids initiated within the specified time frame. Exceptin fr Prir t Arrival: Dcumentatin f crystallid fluids administered prir t arrival t the hspital (e.g., ambulance, nursing hme) that are part f the medical recrd are acceptable if the dcumentatin f fluid administratin cntains the type, vlume, start time, and either a rate, duratin, r end time f the fluid infusin. A physician/apn/pa rder fr fluids administered prir t arrival is nt required. Exceptin fr Operating Rm (OR): Crystallid fluids administered in the OR by a physician/apn/pa are acceptable withut an rder if a fluid type, an infusin start time, and an infusin rate r infusin end time is dcumented. T determine if the target rdered vlume was cmpletely infused, ne f the fllwing must be dcumented alng with the infusin start time. If ne f the fllwing is nt dcumented, d nt use the fluids tward the target rdered vlume: An infusin rate Infusin duratin r time ver which t infuse Infusin end r cmpletin time Examples: Order fr 1500 ml (30 ml/kg) f nrmal saline ver 1 hur started at 08:00. There is n infusin end time dcumented, and n dcumentatin Specificatins Manual fr Hspital Inpatient Quality Measures Page 8
indicating the 1500 ml was nt infused. The infusin end time can be determined based n the duratin in the rder. Select Value 1. Order fr 1000 ml (30 ml/kg) nrmal saline blus started at 09:30. The nurse dcumented an infusin rate f 1000 ml/hur. There is n fluid blus end time dcumented, and n dcumentatin indicating the 1000 ml was nt infused. The infusin end time can be determined based n the rate. Select Value 1. Order fr 2000 ml (30 ml/kg) nrmal saline blus started at 08:30. There is n infusin rate dcumented and n fluid blus end time dcumented. An infusin end time cannt be determined. Chse Value 2. If a rate r duratin t infuse fluids cntained within the rder is different frm the rate r duratin the fluids were actually administered, use the rate r duratin the fluids were actually administered ver. Fluid Order: 0.9% NS 1000 ml blus at 150 ml/hr Nurse dcuments a start time f 1500 and end time f 1800 fr the 1000 ml blus Use the start and stp time dcumented by nursing that reflects the duratin ver which the fluids were actually administered. Only thse crystallid fluids given at a rate greater than 125 ml/hur shuld be used twards the target rdered vlume. D nt use crystallid fluids given at 125 ml/hr r less tward the target rdered vlume. Acceptable fluids are crystallid r balanced crystallid slutins. Crystallid fluids r balanced crystallid fluids that are given t dilute medicatins are acceptable t cunt twards the target rdered vlume. Crystallid fluid vlumes t which the fllwing electrlytes have been added may be cunted tward the target rdered vlume requirement: ptassium, magnesium, calcium, lactate, acetate, r glucnate. Only abstract fluids administered thrugh the intravenus r intrasseus rute. If there is dcumentatin that the patient has an implanted ventricular assist device (VAD) prir t r at the time f identifying need fr crystallid fluids, chse Value 4 regardless f the vlume and rate f crystallid fluids rdered. Physician/APN/PA r nursing dcumentatin indicating patient r authrized patient advcate has refused IV fluid administratin prir t r within 6 hurs fllwing presentatin f septic shck can be used t select Value 4. Decisin t Admit Date Ratinale: The data element is being updated with new guidance. Ntes fr Abstractin Change t: If the date f the decisin t admit t bservatin r inpatient status is unable t be determined frm medical recrd dcumentatin, select UTD. The medical recrd must be abstracted as dcumented (taken at face value ). When the date dcumented is bviusly in errr (nt a valid frmat/range r utside f the Specificatins Manual fr Hspital Inpatient Quality Measures Page 9
parameters f care [after the Discharge Date]) and n ther dcumentatin is fund that prvides this infrmatin, the abstractr shuld select UTD. Examples: Dcumentatin indicates the Decisin t Admit Date was 03-42-20xx. N ther dcumentatin in the list f ONLY ACCEPTABLE SOURCES prvides a valid date. Since the Decisin t Admit Date is utside f the range listed in the Allwable Values fr Day, it is nt a valid date and the abstractr shuld select UTD. Patient expires n 02-12-20xx and all dcumentatin within the ONLY ACCEPTABLE SOURCES indicates the Decisin t Admit Date was 03-12-20xx. Other dcumentatin in the medical recrd supprts the date f death as being accurate. Since the Decisin t Admit Date is after the Discharge Date (death), it is utside f the parameter f care and the abstractr shuld select UTD. Nte: Transmissin f a case with an invalid date as described abve will be rejected frm the CMS Clinical Warehuse and the Jint Cmmissin s Data Warehuse. Use f UTD fr Decisin t Admit Date allws the case t be accepted int the warehuse. When reviewing ED recrds d NOT include any dcumentatin frm external surces (e.g., ambulance recrds, physician/advanced practice nurse/physician assistant [physician/apn/pa] ffice recrd, labratry reprts r ECGs) btained prir t arrival. The intent is t utilize any dcumentatin that reflects prcesses that ccurred in the ED r hspital. Fr purpses f this data element, the surce Emergency Department recrd includes any dcumentatin frm the time f ED arrival t the time the patient physically departed frm the ED. ED departure is at 11:00 n 03-12-20xx. The attending physicians admit rders written in the inpatient recrd at 10:00 n 03-12-20xx are cnsidered part f the ED recrd. Disregard physician/apn/pa narrative dcumentatin f a cnsult r rders fr cnsult, transfer t anther physician s service, r discussin with anther physician since this des nt reflect a decisin was made. If there is mre than ne date f dcumentatin fr the decisin t admit, use the fllwing rder t determine which date t abstract. 1. Specified date the decisin t admit was dcumented. 2. Specified date the decisin t admit was dcumented in a nn-narrative lcatin (e.g., flwsheet, checklist, screening). 3. Nte pened date fr the decisin t admit dcumented in a nn-narrative lcatin withut a specified date (e.g., flwsheet, checklist, screening). 4. Nte pened date fr narrative dcumentatin identifying the decisin t admit was made withut a specified date. Decisin t Admit Date includes physician/apn/pa dcumentatin f a decisin t send the patient t cath lab r surgery. The ED physician dcuments that he/she is sending the patient t the OR fr surgery. The decisin t admit t bservatin r inpatient status date will abstract as the date this was dcumented. Specificatins Manual fr Hspital Inpatient Quality Measures Page 10
Use the date frm the earliest dcumentatin f decisin t admit fr either bservatin r inpatient. The physician rdered Admit Observatin Service. Fur hurs later the physician wrte an rder t admit the patient t inpatient status. These rders were written while the patient was still receiving care in the ED. Use the earlier rder fr Observatin Services t abstract as date and time. If it can be determined that the patient arrived n the same date and departed n the same date, the arrival date can be used as the decisin t admit t bservatin r inpatient status date. Data fields representing decisin t admit in electrnic dcumentatin fr this specific episde f care are acceptable t use as lng as they are the earliest physician/apn/pa dcumentatin and clearly defined t capture the date an bservatin status r inpatient admit decisin was dcumented. Infrmatin fund in an electrnically interfaced event lg r Admit/Decisin/Transfer (ADT) is acceptable prvided this infrmatin is part f the submitted medical recrd cvering the arrival t discharge date being abstracted. Examples: Decisin t Admit Disp Dispsitin set t admit Fr purpses f this data element Decisin t Admit Date is the date n which the physician/apn/pa makes the decisin t admit the patient frm the emergency department t the hspital. This will nt necessarily cincide with the date the patient is fficially admitted t inpatient status. If the decisin t admit the patient t bservatin r inpatient status is made, but the actual request fr a bed is delayed until an inpatient bed is available, recrd the date the physician/apn/pa cmmunicated the decisin t admit. If the decisin t admit t bservatin r inpatient status date is dated prir t the date f patient arrival r after the date f departure, select UTD. Fr dcumentatin f a decisin t admit accmpanied by an indicatr, the table belw shuld be used. Dcumentatin cntaining a psitive indicatr shuld be used fr a decisin t admit, dcumentatin cntaining a negative indicatr shuld nt be used fr a decisin t admit. Psitive Indicatrs Plan t admit Dctr accepts admissin Plan t hspitalize Admit t dctr Need t admit Negative Indicatrs Request admissin May need admissin Dctr will accept patient Recmmend admissin Wuld like t admit Specificatins Manual fr Hspital Inpatient Quality Measures Page 11
Decisin t Admit Time Ratinale: The data element is being updated with new guidance. Ntes fr Abstractin Change t: Fr times that include secnds, remve the secnds and recrd the military time. 15:00:35 wuld be recrded as 15:00. If the time f the decisin t admit t bservatin r inpatient status is unable t be determined frm medical recrd dcumentatin, select UTD. The medical recrd must be abstracted as dcumented (taken at face value ). When the time dcumented is bviusly in errr (nt a valid frmat/range) and n ther dcumentatin is fund that prvides this infrmatin, the abstractr shuld select UTD. Dcumentatin indicates the Decisin t Admit Time was 3300. N ther dcumentatin in the list f ONLY Acceptable Surces prvides a valid time. Since the Decisin t Admit Time is utside f the range in the Allwable Values fr Hur, it is nt a valid time and the abstractr shuld select UTD. Nte: Transmissin f a case with an invalid time as described abve will be rejected frm the CMS Clinical Warehuse and the Jint Cmmissin s Data Warehuse. Use f UTD fr Decisin t Admit Time allws the case t be accepted int the warehuse. When reviewing ED recrds d NOT include any dcumentatin frm external surces (e.g., ambulance recrds, physician/advanced practice nurse/physician assistant [physician/apn/pa] ffice recrd, labratry reprts, r ECGs) btained prir t arrival. The intent is t utilize any dcumentatin which reflects prcesses that ccurred in the ED r hspital. Fr purpses f this data element, the surce Emergency Department recrd includes any dcumentatin frm the time f ED arrival t the time the patient physically departed frm the ED. ED departure is at 11:00 n 03-12-20XX. The attending physicians admit rders written in the inpatient recrd at 10:00 n 03-12-20XX are cnsidered part f the ED recrd. Disregard physician/apn/pa narrative dcumentatin f a cnsult r rders fr cnsult, transfer t anther physician s service, r discussin with anther physician since this des nt reflect a decisin was made. Examples that reflect a decisin t admit was NOT made: ED physician nte states Discussed case with hspitalist. This is nly dcumentatin that a discussin ccurred, there is n dcumentatin regarding a decisin t admit. ED physician nte states Discussed patient with Dr. Jnes wh recmmends admissin. This reflects a discussin ccurred and a recmmendatin was made t admit but des nt indicate a decisin was made t admit. Specificatins Manual fr Hspital Inpatient Quality Measures Page 12
ED physician nte states Cntacted Dr. Smith fr admissin cnsult. This reflects a cnsult has been requested fr admissin but des nt indicate a decisin t admit has been made. ED physician nte states Pssible admissin pending cardilgy cnsult. This reflects a cnsult was rdered and admissin is pssible but des nt indicate a decisin t admit has been made. Examples that reflect a decisin t admit was made: ED physician nte states Discussed case with hspitalist n call, plan t admit. The nte references a discussin with anther physician with plan t admit dcumented, indicating a decisin t admit has been made. ED physician nte states Discussed case with Dr. Brwn wh will admit patient t ICU. The nte references a discussin with anther physician with wh will admit patient dcumented, indicating a decisin t admit has been made. If there is mre than ne time f dcumentatin fr the decisin t admit, use the fllwing rder t determine which time t abstract. 1. Specified time the decisin t admit was dcumented. 2. Specified time the decisin t admit was dcumented in a nn-narrative lcatin (e.g., flwsheet, checklist, screening). 3. Nte pened time fr the decisin t admit dcumented in a nn-narrative lcatin withut a specified time (e.g., flwsheet, checklist, screening). 4. Nte pened time fr narrative dcumentatin identifying the decisin t admit was made withut a specified time. Decisin t Admit Time includes physician/apn/pa dcumentatin f a decisin t send the patient t cath lab r surgery. The ED physician dcuments that he/she is sending the patient t the OR fr surgery. The decisin t admit t bservatin r inpatient status time will abstract as the time this was dcumented. Use the time frm the earliest dcumentatin fr either bservatin r inpatient. The physician rdered Admit Observatin Services. Fur hurs later the physician wrte an rder t admit the patient t inpatient status. These rders were written while the patient was still receiving care in the ED. Use the earlier rder fr Observatin Services t abstract decisin t admit time. Data fields representing decisin t admit in electrnic dcumentatin fr this specific episde f care are acceptable t use as lng as they are the earliest physician/apn/pa dcumentatin and clearly defined t capture the time an bservatin status r inpatient admit decisin was dcumented. Infrmatin fund in an electrnically interfaced event lg r Admit/Decisin/Transfer (ADT) is acceptable prvided this infrmatin is part f the submitted medical recrd cvering the arrival t discharge time being abstracted. Examples: Decisin t Admit Disp Dispsitin set t admit Fr purpses f this data element Decisin t Admit Time is the time the physician/apn/pa cmmunicates the decisin t admit the patient t bservatin r Specificatins Manual fr Hspital Inpatient Quality Measures Page 13
inpatient status frm the emergency department t the hspital. This will nt necessarily cincide with the time the patient is fficially admitted t inpatient status. If the decisin t admit the patient t bservatin r inpatient status is made, but the actual request fr a bed is delayed until an inpatient bed is available, recrd the time the physician/apn/pa cmmunicated the decisin t admit. If dcumentatin f the decisin t admit t bservatin r inpatient status time is prir t arrival r after departure frm the ED, select, UTD. The APN saw the patient in the clinic and sent him/her t the ED fr admissin. Select UTD. Fr dcumentatin f a decisin t admit accmpanied by an indicatr, the table belw shuld be used. Dcumentatin cntaining a psitive indicatr shuld be used fr a decisin t admit, dcumentatin cntaining a negative indicatr shuld nt be used fr a decisin t admit. Psitive Indicatrs Plan t admit Dctr accepts admissin Plan t hspitalize Admit t dctr Need t admit Negative Indicatrs Request admissin May need admissin Dctr will accept patient Recmmend admissin Wuld like t admit Dcumentatin f Septic Shck Ratinale: T reduce abstractin burden, the data element is being remved in its entirety. Remve in Index and Data Dictinary in its entirety: Dcumentatin f Septic Shck Influenza Vaccinatin Status Ratinale: The Influenza Vaccinatin Status data element is being updated with new and clarifying guidance. Ntes fr Abstractin Add new sub-bullet pint under first bullet pint: Only influenza vaccines administered during August thrugh March are acceptable. Add new 11th, 12th, and 13th bullet pints: If it is dcumented in the chart that the patient s influenza vaccinatin status is up t date r current, select Allwable Value 2. Dcumentatin f up t date r current in the vaccinatin recrd that des nt reference the influenza vaccine is nt sufficient t select Allwable Value 2. Specificatins Manual fr Hspital Inpatient Quality Measures Page 14
Dcumentatin f the acrnym UTD, even with specific reference t the influenza vaccine, is nt sufficient t select Allwable Value 2. Dcumentatin frm a pre-admissin screening r previus episde f care indicating that the patient received the influenza vaccine with a date frm the current seasn wuld be acceptable t chse Value 2. Remve last tw bullet pints: If it is dcumented in the chart that the patient s influenza vaccinatin status is up t date r current, select Allwable Value 2. Dcumentatin f up t date r current in the vaccinatin recrd that des nt reference the influenza vaccine is nt sufficient t select Allwable Value 2. Dcumentatin f the acrnym UTD, even with specific reference t the influenza vaccine, is nt sufficient t select Allwable Value 2. Initial Hyptensin Ratinale: The data element is being updated t prvide additinal guidance t the abstractr. Definitin Change t: Dcumentatin f the presence f initial hyptensin within the specified time frame and prir t the cmpletin f the target rdered vlume (30 ml/kg r up t10% less than 30 ml/kg) f crystallid fluids. Suggested Data Cllectin Questin Change frm: Was initial hyptensin present 6 hurs prir t r within 6 hurs fllwing Severe Sepsis Presentatin Date and Time? Change t: Was initial hyptensin present within the specified time frame? Allwable Values Change frm: 1 (Yes) Initial Hyptensin was present 6 hurs prir t r within 6 hurs fllwing Severe Sepsis presentatin. 2 (N) Initial Hyptensin was nt present 6 hurs prir t r within 6 hurs fllwing Severe Sepsis presentatin r unable t determine frm medical recrd dcumentatin. Change t: 1 (Yes) Initial Hyptensin was present within the specified time frame. 2 (N) Initial Hyptensin was nt present within the specified time frame r unable t determine frm medical recrd dcumentatin. Ntes fr Abstractin Change t: The specified time frame fr assessing Initial Hyptensin is 6 hurs prir t r within 6 hurs fllwing Severe Sepsis Presentatin Date and Time. Specificatins Manual fr Hspital Inpatient Quality Measures Page 15
The criteria fr determining that Initial Hyptensin was present are as fllws: Tw hyptensive bld pressure readings frm measurements taken at different times within the specified time frame. The hyptensive bld pressure readings d nt need t be cnsecutive but need t be within 3 hurs f each ther. Acceptable readings are: systlic bld pressures <90, r mean arterial pressures (MAP) <65 r a decrease in systlic bld pressure by >40 mm/hg. Physician/APN/PA dcumentatin must be present in the medical recrd indicating a >40 mmhg decrease in SBP has ccurred and is related t infectin r severe sepsis and nt ther causes. Use the time the hyptensive bld pressures were taken r btained. If time taken r btained is nt available, use recrded r dcumented time. D nt abstract hyptensive values frm narrative charting unless there is n ther dcumentatin that reflects the time that the same hyptensive values were btained. Hyptensive BPs btained within the perating rm (OR) shuld nt be used. Hyptensive BPs dcumented frm an rthstatic BP evaluatin shuld nt be used. Fr the fllwing, physician/apn/pa dcumentatin prir t r within 24 hurs after Severe Sepsis Presentatin Time is required. If hyptensin (SBP <90 mmhg r MAP <65 mmhg) is due t the fllwing, it shuld nt be used. Inferences shuld nt be made. The abnrmal value r reference t the abnrmal value must be in the same dcumentatin. Nrmal fr that patient Is due t a chrnic cnditin Is due t a medicatin Hyptensive after pain meds If a hyptensive value is due t an acute cnditin that has a nn-infectius surce/prcess, it shuld nt be used (Refer t Severe Sepsis Present criteria a t determine if the surce f the acute cnditin is an infectin). BP 85/50 r/t bld lss 2 liters lst via GI bleed (bld lss is the acute cnditin and GI bleed is the nn-infectius surce). If a hyptensive value shuld nt be used based n the abve guidance, all instances f less severe values shuld nt be used. BP 80/50 secndary t Lasix (systlic bld pressures 80 wuld nt be used). If a hyptensive value is due t the fllwing, the criteria value shuld be used. Acute cnditin Prgress Nte: Hyptensin r/t dehydratin. Acute n chrnic cnditin H&P: Hyptensin due t acute exacerbatin f chrnic heart failure. Specificatins Manual fr Hspital Inpatient Quality Measures Page 16
Infectin Physician Nte: Sepsis, hyptensive. Dcumentatin f a term that represents r is defined by an SBP <90 mmhg r MAP <65 mmhg is acceptable in place f an abnrmal value. Hyptensin (Systlic bld pressure <90 mmhg). If within the same physician/apn/pa dcumentatin, there is cnflicting dcumentatin indicating hyptensin is nrmal fr the patient, r due t a chrnic cnditin r medicatin AND due t r pssibly due t an infectin, Severe Sepsis, r Septic Shck, the criteria value shuld be used. Hyptensive pst medicatins, pssibly r/t sepsis. If within 24 hurs after Severe Sepsis Presentatin Time there is cnflicting infrmatin within tw r mre separate pieces f physician/apn/pa dcumentatin indicating hyptensin is nrmal fr the patient, r due t a chrnic cnditin r medicatin AND due t r pssibly due t an infectin, Severe Sepsis, r Septic Shck, abstract based n the latest piece f dcumentatin within the 24-hur perid. Nte 1200: Antihypertensive discntinued due t hyptensin. Nte 1600: Sepsis with hyptensin and SIRS criteria. Hyptensive readings shuld be used. Initial hyptensin is hyptensin that is present prir t the target rdered vlume f crystallid fluids being cmpletely infused. If hyptensin was present within 6 hurs prir t r within 6 hurs fllwing Severe Sepsis Presentatin Date and Time, select Value 1. If hyptensin was nt present within 6 hurs prir t r within 6 hurs fllwing Severe Sepsis Presentatin Date and Time, select Value 2. If within 24 hurs f the Severe Sepsis Presentatin Time there is physician/apn/pa r nursing dcumentatin indicating a hyptensive reading is invalid, errneus r questinable, disregard that reading when determining the presence f Initial Hyptensin. If there is physician/apn/pa dcumentatin indicating the patient des nt have hyptensin and it is referencing a specific time perid in which there was ne r mre hyptensive values recrded, the hyptensive value(s) shuld nt be used. The dcumentatin must be within 24 hurs fllwing the lw bld pressure value(s). Prgress nte: Nt hyptensive in ED. Hyptensive values in ED shuld nt be used. Use f dcumentatin in pre-hspital recrds (e.g., ambulance recrds, nursing hme recrds) that is cnsidered part f the medical recrd is acceptable fr determining Initial Hyptensin. Specificatins Manual fr Hspital Inpatient Quality Measures Page 17
Initial Lactate Level Cllectin Ratinale: The data element is being updated t reduce abstractr burden and prvide clarity. Definitin Change t: Dcumentatin f cllectin f an initial lactate level within the specified time frame. Suggested Data Cllectin Questin Change frm: Was an initial lactate level drawn between 6 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis? T: Was an initial lactate level drawn within the specified time frame? Allwable Values Change frm: 1 (Yes) An initial lactate level was drawn in the time windw between 6 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis. 2 (N) An initial lactate level was nt drawn in the time windw between 6 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis, r unable t determine. T: 1 (Yes) An initial lactate level was drawn within the specified time frame. 2 (N) An initial lactate level was nt drawn within the specified time frame, r unable t determine. Ntes fr Abstractin Remve: If there are multiple lactate levels, nly abstract the level drawn clsest t the time f presentatin f severe sepsis. If there is a lactate level bth befre and after presentatin f severe sepsis that are the same time apart, use the level prir t presentatin. That lactate level is the initial lactate level fr purpses f this data element. Add new first and secnd bullet pints: The specified time frame within which an initial lactate must be drawn is within 6 hurs prir thrugh 3 hurs fllwing severe sepsis presentatin. If multiple lactate levels are drawn within the specified time frame, use the lactate drawn PRIOR t the Severe Sepsis Presentatin Time with the HIGHEST level. If multiple lactate levels are drawn ONLY in the 3 hurs after the Severe Sepsis Presentatin Time, use the lactate drawn with the HIGHEST level within this time frame. If there is mre than ne time f dcumentatin fr the Initial Lactate Level Cllectin, use the fllwing rder t determine which time t abstract. 1. Labratry dcumentatin indicating date and time lactate was drawn. 2. Date and Time the lactate is dcumented as drawn in a nn-narrative lcatin (e.g., sepsis flwsheet, checklist, screening). 3. Narrative nte indicating lactate is drawn with an assciated date and time. Specificatins Manual fr Hspital Inpatient Quality Measures Page 18
Change frm seventh bullet pint t third bullet pint: If there is n dcumentatin indicating a lactate was drawn r cllected, but there is supprtive dcumentatin that a lactate was drawn, use the earliest supprtive dcumentatin (e.g., lactate sent t lab, lactate received, lactate result). Initial Lactate Level Date Ratinale: The data element is being updated t reduce abstractr burden and prvide clarity. Ntes fr Abstractin Remve: If there are multiple lactate levels, nly abstract the level drawn clsest t the time f presentatin f severe sepsis. If there is a lactate level bth befre and after presentatin f severe sepsis that are the same time apart, use the level prir t presentatin. That lactate level is the initial lactate level fr purpses f this data element. Add new first bullet pint: If there is mre than ne date f dcumentatin fr the Initial Lactate Level Cllectin, use the fllwing rder t determine which date t abstract. 1. Labratry dcumentatin indicating date lactate was drawn. 2. Nn-narrative lcatin indicating lactate was drawn with an assciated date (e.g., sepsis flwsheet, checklist, screening). 3. Narrative nte indicating lactate is drawn with an assciated date. Change frm furth bullet pint t secnd bullet pint: If there is nt a lactate draw r cllected date dcumented, but there is supprtive dcumentatin that a lactate was drawn, use the date f the earliest supprtive dcumentatin (e.g., lactate sent t lab, lactate received date, lactate result date). Initial Lactate Level Time Ratinale: The data element is being updated t reduce abstractr burden and prvide clarity. Ntes fr Abstractin Remve: If there are multiple lactate levels, nly abstract the level drawn clsest t the time f presentatin f severe sepsis. If there is a lactate level bth befre and after presentatin f severe sepsis that are the same time apart, use the level prir t presentatin. That lactate level is the initial lactate level fr purpses f this data element. Add new first bullet pint: If there is mre than ne time f dcumentatin fr the Initial Lactate Level Cllectin, use the fllwing rder t determine which time t abstract. 1. Labratry dcumentatin indicating time lactate was drawn. 2. Nn-narrative lcatin indicating lactate was drawn with an assciated time (e.g., sepsis flwsheet, checklist, screening). 3. Narrative nte indicating lactate is drawn with an assciated time. Specificatins Manual fr Hspital Inpatient Quality Measures Page 19
Change frm furth bullet pint t secnd bullet pint: If there is nt a lactate draw r cllected time dcumented, but there is supprtive dcumentatin that a lactate was drawn, use the time f the earliest supprtive dcumentatin (e.g., lactate sent t lab, lactate received time, lactate result time). Persistent Hyptensin Ratinale: The data element is being updated t prvide additinal guidance t the abstractr. Ntes fr Abstractin Change t: The criteria fr determining that persistent hyptensin r new nset f hyptensin was present are as fllws: In the ne hur fllwing cnclusin f administratin f the target rdered vlume f crystallid fluids, tw cnsecutive dcumented bld pressure readings f either: systlic bld pressure <90, r mean arterial pressure (MAP) <65 r a decrease in systlic bld pressure by >40 mm/hg. Physician/APN/PA dcumentatin must be present in the medical recrd indicating a >40 mmhg decrease in SBP has ccurred and is related t infectin, severe sepsis r septic shck and nt ther causes. Use the time the hyptensive bld pressures were taken r btained. If time taken r btained is nt available, use recrded r dcumented time. D nt abstract hyptensive values frm narrative charting unless there is n ther dcumentatin that reflects the time that the same hyptensive values were btained. Hyptensive BPs btained within the perating rm (OR) shuld nt be used. Hyptensive BPs dcumented frm an rthstatic BP evaluatin shuld nt be used. Determining presence f persistent hyptensin (lw is SBP <90 r MAP <65): If there were n bld pressures r nly ne bld pressure recrded within the hur: If the nly bld pressure within the hur is nrmal, select Value 2. If there is n bld pressure r the nly bld pressure within the hur is lw, select Value 3. If there are mre than tw bld pressures dcumented, refer t the last tw cnsecutive bld pressures within the hur: If there is a nrmal bld pressure fllwed by anther nrmal bld pressure, select Value 2. If there is a nrmal bld pressure fllwed by a lw bld pressure, select Value 3. If there is a lw bld pressure fllwed by a nrmal bld pressure, select Value 2. If there is a lw bld pressure fllwed by anther lw bld pressure, select Value 1. Fr the fllwing, physician/apn/pa dcumentatin prir t r within 24 hurs after Severe Sepsis Presentatin Time is required. Specificatins Manual fr Hspital Inpatient Quality Measures Page 20
Release Ntes Versin 5.5 If hyptensin (SBP <90 mmhg r MAP <65 mmhg) is due t the fllwing, it shuld nt be used. Inferences shuld nt be made. The abnrmal value r reference t the abnrmal value must be in the same dcumentatin. Nrmal fr that patient Is due t a chrnic cnditin Is due t a medicatin Hyptensive after pain meds. If a hyptensive value is due t an acute cnditin that has a nn-infectius surce/prcess, it shuld nt be used (Refer t Severe Sepsis Present criteria a t determine if the surce f the acute cnditin is an infectin). BP 85/50 r/t bld lss 2 liters lst via GI bleed (bld lss is the acute cnditin and GI bleed is the nn-infectius surce. If a hyptensive value shuld nt be used based n the abve guidance, all instances f less severe values shuld nt be used. BP 80/50 secndary t Lasix (systlic bld pressures 80 wuld nt be used). If a hyptensive value is due t the fllwing, the criteria value shuld be used. Acute cnditin Prgress Nte: Hyptensin r/t dehydratin. Acute n chrnic cnditin H&P: Hyptensin due t acute exacerbatin f chrnic heart failure. Infectin Physician Nte: Sepsis, hyptensive. Dcumentatin f a term that represents r is defined by an SBP <90 mmhg r MAP <65 mmhg is acceptable in place f an abnrmal value. Hyptensin (Systlic bld pressure <90 mmhg). If within the same physician/apn/pa dcumentatin, there is cnflicting dcumentatin indicating hyptensin is nrmal fr the patient, r due t a chrnic cnditin r medicatin AND due t r pssibly due t an infectin, Severe Sepsis, r Septic Shck, the criteria value shuld be used. Hyptensive pst medicatins, pssibly r/t sepsis. If within 24 hurs after Severe Sepsis Presentatin Time there is cnflicting infrmatin within tw r mre separate pieces f physician/apn/pa dcumentatin indicating hyptensin is nrmal fr the patient, r due t a chrnic cnditin r medicatin AND due t r pssibly due t an infectin, Severe Sepsis, r Septic Shck, abstract based n the latest piece f dcumentatin within the 24-hur perid. Nte 1200: Antihypertensive discntinued due t hyptensin. Nte 1600: Sepsis with hyptensin and SIRS criteria. Specificatins Manual fr Hspital Inpatient Quality Measures Page 21
Hyptensive readings shuld be used. Begin abstracting at the time the target rdered vlume cncludes; abstract fr the time perid that fllws fr the next hur nly. Chse Value 1 if persistent hyptensin r new nset f hyptensin was present, chse Value 2 if persistent hyptensin r new nset f hyptensin was nt present. If the cmpletin time f the target rdered vlume is dcumented in the medical recrd use that time as the start fr the ne hur within which t determine presence f persistent hyptensin r new nset f hyptensin. If the cmpletin time f the target rdered vlume is nt dcumented in the medical recrd use the fllwing criteria t determine the cnclusin time. If the rder includes a time frame ver which t infuse the crystallid fluid, identify the time the fluids are started and add t that the duratin identified in the rder. This will represent the cnclusin f crystallid fluids. An rder fr 1500 ml ver 1 hur and the infusin is started at 10:00. Add 1 hur t the start time t determine infusin cnclusin time f 11:00. If the rder includes a rate at which t infuse the crystallid fluids, the end time can be calculated based n the vlume, the rate and the start time. An rder fr 1500 ml at 1000 ml/hur and the infusin is started at 10:00. The time ver which 1500 ml is infused is the vlume divided by the rate. 1500 ml divided by 1000 ml/hur is 1.5 hurs. Add 1.5 hurs t the start time t determine infusin cnclusin time f 11:30. If the rder is fr mre than 30 ml/kg, 30 ml/kg will have been infused befre the entire vlume rdered is infused. An rder fr 3000 ml ver 2 hurs, infusin started at 10:00. Patient weighs 80 kg, 30 ml/kg target vlume is 2400 ml (as determined fr Crystallid Fluid Administratin). Divide the ttal vlume rdered by the infusin duratin in minutes t determine the infusin rate (3000 ml/120 minutes = 25 ml/minute). Divide the 30 ml/kg target vlume by the infusin rate t determine the number f minutes it takes t infuse the target vlume (2400 ml/25 ml/min = 96 minutes). Add the number f minutes t infuse the target vlume t the infusin start time t determine the time 30 ml/kg was cmpleted (10:00 + 96 minutes = 11:36). If the rder states blus r wide pen and des nt include an infusin rate r time ver which t infuse the fluids, an infusin rate recrded in the medical recrd by a nurse OR fluid blus cmpleted time r end time can be used t determine when the target rdered vlume was cmpleted. Acceptable crystallid fluids are identified in the Crystallid Fluid Administratin data element. If the end time f the target rdered vlume f crystallid fluids cannt be determined, select Value 3. If crystallid fluids were administered but at a vlume less than the target rdered vlume, chse Value 4. Use f dcumentatin in pre-hspital recrds (e.g., ambulance recrds, nursing hme recrds) that are cnsidered part f the medical recrd is acceptable fr determining the presence f Persistent Hyptensin. Specificatins Manual fr Hspital Inpatient Quality Measures Page 22