AHRQ Quality Indicators

Guide to Patient Safety Indicators

Department of Health and Human Services

Agency for Healthcare Research and Quality
www.ahrq.gov

March 13, 2003

AHRQ Pub. No. 03-R203
Revision 1 (May 28, 2003)
Citation
AHRQ Quality Indicators Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare
Research and Quality, 2003. AHRQ Pub.03-R203
Preface
In health care as in other arenas, that which cannot be measured is difficult to improve. Providers,
consumers, policy makers, and others seeking to improve the quality of health care need accessible,
reliable indicators of quality that they can use to flag potential problems or successes; follow trends over
time; and identify disparities across regions, communities, and providers. As noted in a 2001 Institute of
Medicine study, Envisioning the National Health Care Quality Report, it is important that such measures
cover not just acute care but multiple dimensions of care: staying healthy, getting better, living with illness
or disability, and coping with the end of life.

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) are one
Agency response to this need for multidimensional, accessible quality indicators. They include a family of
measures that providers, policy makers, and researchers can use with inpatient data to identify apparent
variations in the quality of inpatient or outpatient care. AHRQs Evidence-Based Practice Center (EPC) at
the University of California and Stanford University adapted, expanded, and refined these indicators
based on the original Healthcare Cost and Utilization Project (HCUP) Quality Indicators developed in the
early 1990s.

The new AHRQ QIs are organized into three modules, which are being published as a series:
Prevention Quality Indicators, Inpatient Quality Indicators, and Patient Safety Indicators. All three
modules are available and can be downloaded from AHRQs Web site at
http://www.qualityindicators.ahrq.gov/. The QIs were developed as an accessible and low-cost screening
tool to help organizations identify potential problems in quality of care and target promising areas for in-
depth review.

This third module focuses on potentially preventable complications and iatrogenic events for
patients treated in hospitals. The Patient Safety Indicators (PSIs) are measures that screen for adverse
events that patients experience as a result of exposure to the health care system; these events are likely
amenable to prevention by changes at the system or provider level. The PSIs include 20 hospital-level
and 6 area level indicators.

Full technical information on the first two modules can be found in Evidence Report for
Refinement of the HCUP Quality Indicators, prepared by the UCSF-Stanford EPC. It can be accessed at
AHRQs Web site. The technical report for the third module, entitled Evidence Report for Measures of
Patient Safety Based on Hospital Administrative DataThe Patient Safety Indicators, is also available on
AHRQs Web site.

Improving the quality of inpatient hospital services is a critical part of efforts to provide high quality
health care in the United States. This guide is intended to facilitate such efforts. As always, we would
appreciate hearing from those who use our measures and tools so that we can identify how they are
used, how they can be refined, and how we can measure and improve the quality of the tools themselves.

Irene Fraser, Ph.D., Director

Center for Organization and Delivery Studies

The programs for the Patient Safety Indicators (PSIs) can be downloaded from
http://www.qualityindicators.ahrq.gov/. Instructions on how to use the programs to calculate the PSI
rates are contained in the companion text, Patient Safety Indicators: Software Documentation.

We welcome your feedback. Support staff are available to answer your questions and respond to
comments. They can be reached at [email protected].

Version 2.1 i Revision 1 (May 28, 2003)

Acknowledgments
This product is based on the work of many individuals who contributed to its development and
testing.

The following staff from the Evidence-based Practice Center (EPC) at UCSF-Stanford
performed the evidence review, completed the empirical evaluation, and created the programming code
and technical documentation for the new Quality Indicators:

Core Project Team

Kathryn M. McDonald, M.M. (Stanford), Sheryl M. Davies, M.A. (Stanford)
principal investigator Bradford W. Duncan, M.D. (Stanford)
Kaveh G. Shojania, M.D. (UCSF)
Investigators
Patrick S. Romano, M.D., M.P.H. (UC-Davis) Angela Hansen, B.A. (Stanford), EPC
Jeffrey Geppert, J.D. (Stanford) Research Assistant

The following staff from Social & Scientific Systems, Inc., developed this software product,
documentation, and guide:

Programmers Technical Writer

Leif Karell Patricia Burgess
Kathy McMillan
Fred Rohde Graphics Designer
Laura Spofford

Contributors from the Agency for Healthcare Research and Quality:

Anne Elixhauser, Ph.D. Marlene Miller, M.D., M.Sc.

Denise Remus, Ph.D., R.N. Margaret Coopey, R.N., M.G.A, M.P.S.
H. Joanna Jiang, Ph.D.

We wish to also acknowledge the following individuals and organizations for their aid in this
report: Doug Staiger, Dept. of Economics, Dartmouth College; Ros McNally, National Primary Care
Research and Development Centre, University of Manchester; Rita Scichilone and the American Health
Information Management Association; the various professional organizations that provided nominatations
for our clinical review panels; the clinical panelists; the peer reviewers of the evidence report; and the
beta-testers of the software products, all of whose input was invaluable.

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Table of Contents
Preface ........................................................................................................................................................... i
Table of Contents..........................................................................................................................................iii
Introduction to the AHRQ Patient Safety Indicators...................................................................................... 1
What Are the Patient Safety Indicators? ................................................................................................... 1
How Can the PSIs be Used to Assess Patient Safety? ............................................................................ 2
What Does this Guide Contain? ................................................................................................................ 2
Origins and Background of the Quality Indicators ........................................................................................ 4
Development of the AHRQ Quality Indicators ........................................................................................... 4
AHRQ Quality Indicator Modules .............................................................................................................. 5
Methods of Identifying, Selecting, and Evaluating the Quality Indicators ..................................................... 6
Step 1: Define the Concepts and the Evaluation Framework ................................................................... 6
Step 2: Search the Literature to Identify Potential PSIs ............................................................................ 8
Step 3: Develop a Candidate List of PSIs ................................................................................................. 9
Step 4: Review the PSIs.......................................................................................................................... 12
Step 5: Evaluate the PSIs Using Empirical Analysis............................................................................... 13
Summary Evidence on the Patient Safety Indicators.................................................................................. 15
Table 1. AHRQ Hospital-Level Patient Safety Indicators ........................................................................ 17
Limitations in Using the PSIs................................................................................................................... 19
Further Research on PSIs ....................................................................................................................... 20
Use of External Cause-of-Injury Codes................................................................................................... 20
Detailed Evidence for Patient Safety Indicators.......................................................................................... 22
Complications of Anesthesia ................................................................................................................... 23
Death in Low-Mortality DRGs.................................................................................................................. 25
Decubitus Ulcer ....................................................................................................................................... 27
Failure to Rescue .................................................................................................................................... 29
Foreign Body Left During Procedure....................................................................................................... 31
Foreign Body Left During Procedure....................................................................................................... 31
Iatrogenic Pneumothorax ........................................................................................................................ 33
Iatrogenic Pneumothorax ........................................................................................................................ 33
Selected Infections Due to Medical Care ................................................................................................ 35
Selected Infections Due to Medical Care ................................................................................................ 35
Postoperative Hemorrhage or Hematoma............................................................................................... 37
Postoperative Hip Fracture...................................................................................................................... 39
Postoperative Physiologic and Metabolic Derangement......................................................................... 41
Postoperative Pulmonary Embolism or Deep Vein Thrombosis ............................................................. 43
Postoperative Respiratory Failure ........................................................................................................... 45
Postoperative Sepsis............................................................................................................................... 47
Postoperative Wound Dehiscence .......................................................................................................... 49
Postoperative Wound Dehiscence .......................................................................................................... 49
Accidental Puncture or Laceration .......................................................................................................... 51
Accidental Puncture or Laceration .......................................................................................................... 51
Transfusion Reaction............................................................................................................................... 53
Transfusion Reaction............................................................................................................................... 53
Birth TraumaInjury to Neonate............................................................................................................. 55
Obstetric TraumaCesarean Delivery ................................................................................................... 57
Obstetric TraumaVaginal Delivery with Instrument ............................................................................. 59
Obstetric TraumaVaginal Delivery without Instrument ........................................................................ 61
References .................................................................................................................................................. 63
Appendix A: Patient Safety Indicators Detailed Definitions ..................................................................... 66
Long-Term Care Facility.............................................................................................................................. 86
Transferred to Acute Care Facility .............................................................................................................. 98
Transferred from Acute Care or Long-Term Care Facility .......................................................................... 98
Diabetes .................................................................................................................................................... 117
Appendix B: Detailed Methods.................................................................................................................. 139
Analysis Approach................................................................................................................................. 139
Empirical Analysis Statistics .................................................................................................................. 142

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Introduction to the AHRQ Patient Safety Indicators
Patient safety is an issue of major national interest. Policymakers, providers, and consumers
have made the safety of care in U.S. hospitals a top priority. The need to assess, monitor, track, and
improve the safety of inpatient care became apparent with publication of the Institute of Medicines series
of reports describing the problem of medical errors1. As our health care system becomes more complex,
the possibility of significant unintended adverse effects increases.

One approach to detecting, characterizing, and reporting potentially preventable adverse events
is to develop screening measures based on routinely collected administrative data. These data can be
used to identify indicators of potential problems that result from exposure to the health care system and
are likely to be prevented as a result of system-level changes.

Hospital administrative data offer a window into the medical care delivered in our nations
hospitals. These data, which are collected as a routine step in the delivery of hospital services, provide
information on patients diagnoses, procedures, age, gender, admission source, and discharge status.
From these data elements, it is possible to construct a picture of the qualityand safetyof medical
care. Although assessments based on administrative data cannot be definitive, they can be used to flag
potential safety problems and success stories, which can then be further investigated and studied.
Hospital associations, individual hospitals, purchasers, regulators, and policymakers at the local, State,
and Federal levels can use readily available hospital administrative data to begin the assessment of
patient safety.

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are a
tool that takes advantage of hospital administrative data. The PSIs represent the current state-of-the-art
in measuring the safety of hospital care through analysis of inpatient discharge data.

What Are the Patient Safety Indicators?

The PSIs are a set of measures that can be used with hospital inpatient discharge data to provide
a perspective on patient safety. Specifically, PSIs screen for problems that patients experience as a
result of exposure to the healthcare system and that are likely amenable to prevention by changes at the
system or provider level. These are referred to as complications or adverse events. PSIs are defined on
two levels: the hospital level and the area level.

Hospital-level indicators provide a measure of the potentially preventable complication for patients
who received their initial care and the complication of care within the same hospitalization. Hospital-
level indicators include only those cases where a secondary diagnosis code flags a potentially
preventable complication.

Area-level indicators capture all cases of the potentially preventable complication that occur in a given
area (e.g., metropolitan service area or county) either during hospitalization or result in subsequent
hospitalization. Area-level indicators are specified to include principal diagnosis, as well as
secondary diagnoses, for the complications of care. This specification adds cases where a patients
risk of the complication occurred in a separate hospitalization.

1
Institute of Medicine. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS
(eds.) Washington DC: National Academy Press, 2000.

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The PSIs include the following hospital-level indicators:

Accidental puncture or laceration Postoperative pulmonary embolism (PE) or

deep vein thrombosis (DVT)
Complications of anesthesia Postoperative respiratory failure
Death in low-mortality diagnosis-related groups Postoperative sepsis
(DRGs)
Decubitus ulcer Postoperative wound dehiscence
Failure to rescue Selected infections due to medical care
Foreign body left during procedure Transfusion reaction
Iatrogenic pneumothorax Birth traumainjury to neonate
Postoperative hemorrhage or hematoma Obstetric traumaCesarean delivery
Postoperative hip fracture Obstetric traumavaginal delivery with
instrument
Postoperative physiologic and metabolic Obstetric traumavaginal delivery without
derangement instrument

In addition, the following PSIs were modified into area-level indicators to assess the total incidence of the
adverse event within geographic areas.

Accidental puncture or laceration

Foreign body left during procedure
Iatrogenic pneumothorax
Selected infections due to medical care
Postoperative wound dehiscence
Transfusion reaction

How Can the PSIs be Used to Assess Patient Safety?

Widespread consensus exists that health care organizations can reduce patient injuries by
improving the environment for safetyfrom implementing technical changes, such as electronic medical
record systems, to improving staff awareness of patient safety risks. Clinical process interventions also
have strong evidence for reducing the risk of adverse events related to a patients exposure to hospital
care.2 PSIs, which are based on computerized hospital discharge abstracts from the AHRQs Healthcare
Cost and Utilization Project (HCUP), can be used to better prioritize and evaluate local and national
initiatives. Analyses of these and similar inexpensive, readily available administrative data sets may
provide a screen for potential medical errors and a method for monitoring trends over time. The scenario
on the following page illustrates one potential application of the PSIs.

What Does this Guide Contain?

This guide provides information that hospitals, State data organizations, hospital associations,
and others can use to decide how to use the PSIs. First, it describes the origin of the entire family of
AHRQ Quality Indicators. Second, it provides an overview of the methods used to identify, select, and
evaluate the AHRQ PSIs. Third, the guide summarizes the PSIs specifically, describes strengths and
limitations of the indicators, documents the evidence that links the PSIs to the quality of health care
services, and then provides in-depth two-page descriptions of each PSI. Finally, two appendices present
additional technical background information. Appendix A outlines the specific definitions of each PSI, with
complete ICD-9-CM coding specifications. Appendix B provides the details of the empirical methods used
to explore the PSIs.

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Evaluating and Improving Quality of Care

A hospital association recognizes its member hospitals need for information that can
help them evaluate the quality of care they provide. There is significant interest in assessing,
monitoring and improving the safety of inpatient care. After learning about the AHRQ PSIs,
the association decides to apply the indicators to the discharge abstract data submitted by
individual hospitals. For each hospital, the association develops a report with graphic
presentation of the risk-adjusted data to show how the hospital performs on each indicator
compared to its peer group, the State as a whole, and other comparable States. National
and regional averages from the AHRQ Healthcare Cost and Utilization Project (HCUP)
database are also provided as additional external benchmarks. Three years of trend data
are included to allow the hospital to examine any changing patterns in its performance.

One member hospital, upon receiving the report, convenes an internal work group
comprised of clinicians and quality improvement professionals to review the information and
identify potential areas for improvement. The hospital leadership is committed to
performance excellence and providing a culture supportive of systems evaluation and
redesign. To begin their evaluation, they apply the AHRQ software to their internal
administrative data to distinguish those patients who experienced the complication or
adverse event from those who did not. This step establishes the focus for chart review.

After the initial analysis of the administrative and clinical data, the work group meets
with clinical departments involved in care of these patients. They begin an in-depth analysis
of the system and processes of care. Through application of process improvement
concepts, they begin to identify opportunities for improvement. After selection of their priority
area (for example, reduction of postoperative complications), they begin work, including:

Review and synthesize the evidence base and best practices from scientific literature.

Work with the multiple disciplines and departments involved in care of surgical patients to
redesign care based on best practices with an emphasis on coordination and
collaboration.

Evaluate information technology solutions.

Implement performance measurements for improvement and accountability.

Incorporate monitoring of performance measurements in the departmental and senior

leadership meetings and include in the Board quality improvement reports.

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Origins and Background of the Quality Indicators
In the early 1990s, in response to requests for assistance from State-level data organizations and
hospital associations with inpatient data collection systems, AHRQ developed a set of quality measures
that required only the type of information found in routine hospital administrative datadiagnoses and
major procedures, along with information on patients age, gender, source of admission, and discharge
status. These States were part of the Healthcare Cost and Utilization Project, an ongoing Federal-State-
private sector collaboration to build uniform databases from administrative hospital-based data.

AHRQ developed these measures, called the HCUP Quality Indicators, to take advantage of a
readily available data sourceadministrative data based on hospital claimsand quality measures that
had been reported elsewhere.2 The 33 HCUP QIs included measures for avoidable adverse outcomes,
such as in-hospital mortality and complications of procedures; use of specific inpatient procedures
thought to be overused, underused, or misused; and ambulatory care sensitive conditions.

Although administrative data cannot provide definitive measures of health care quality, they can
be used to provide indicators of health care quality that can serve as the starting point for further
investigation. The HCUP QIs have been used to assess potential quality-of-care problems and to
delineate approaches for dealing with those problems. Hospitals with high rates of poor outcomes on the
HCUP QIs have reviewed medical records to verify the presence of those outcomes and to investigate
potential quality-of-care problems.3 For example, one hospital that detected high utilization rates for
certain procedures refined patient selection criteria for these procedures to improve appropriate
utilization.

Development of the AHRQ Quality Indicators

Since the original development of the HCUP QIs, the knowledge base on quality indicators has
increased significantly. Risk adjustment methods have become more readily available, new measures
have been developed, and analytic capacity at the State level has expanded considerably. Based on
input from current users and advances to the scientific base for specific indicators, AHRQ funded a
project to refine and further develop the original QIs. The project was conducted by the UCSF-Stanford
EPC.

The major constraint placed on the UCSF-Stanford EPC was that the measures could require
only the type of information found in hospital discharge abstract data. Further, the data elements required
by the measures had to be available from most inpatient administrative data systems. Some State data
systems contain innovative data elements, often based on additional information from the medical record.
Despite the value of these record-based data elements, the intent of this project was to create measures
that were based on a common denominator discharge data set, without the need for additional data
collection. This was critical for two reasons. First, this constraint would result in a tool that could be used
with any inpatient administrative data, thus making it useful to most data systems. Second, this would
enable national and regional benchmark rates to be provided using HCUP data, since these benchmark
rates would need to be calculated using the universe of data available from the States.

2
Ball JK, Elixhauser A, Johantgen M, et al. HCUP Quality Indicators, Methods, Version 1.1: Outcome, Utilization, and
Access Measures for Quality Improvement. (AHCPR Publication No. 98-0035). Healthcare Cost and Utilization
project (HCUP-3) Research notes: Rockville, MD: Agency for Health Care Policy and Research, 1998.

3
Impact: Case Studies Notebook Documented Impact and Use of AHRQ's Research. Compiled by Division of
Public Affairs, Office of Health Care Information, Agency for Healthcare Research and Quality.

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AHRQ Quality Indicator Modules

The work of the UCSF-Stanford EPC resulted in the AHRQ Quality Indicators, which are being
distributed as three separate modules:

Prevention Quality Indicators. These indicators consist of ambulatory care sensitive conditions,
hospital admissions that evidence suggests could have been avoided through high-quality outpatient
care or that reflect conditions that could be less severe, if treated early and appropriately.

Inpatient Quality Indicators. These indicators reflect quality of care inside hospitals and include
inpatient mortality; utilization of procedures for which there are questions of overuse, underuse, or
misuse; and volume of procedures for which there is evidence that a higher volume of procedures is
associated with lower mortality.

Patient Safety Indicators. These indicators focus on potentially preventable instances of

complications and other iatrogenic events resulting from exposure to the health care system.

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Methods of Identifying, Selecting, and Evaluating the Quality
Indicators
Since the literature surrounding PSIs is sparse, the project team used a variety of additional
techniques to identify, select, and evaluate each indicator, including clinician panels, expert coders, and
empirical analyses.

Step 1: Define the Concepts and the Evaluation Framework

In approaching the task of evaluating patient safety indicators based on administrative data, the
project team developed a conceptual framework and standardized definitions of commonly used terms.

Standardized Definitions

In the literature, the distinctions between medical error, adverse events, complications of care,
and other terms pertinent to patient safety are not well established and are often used interchangeably.In
this report, the terms medical error, adverse events or complications, and similar concepts are defined as
follows:

Case finding indicators. Indicators for which the primary purpose is to identify specific cases in
which a medical error may have occurred, for further investigation.

Complication or adverse event. An injury caused by medical management rather than by the
underlying disease or condition of the patient.4 In general, adverse events prolong the
hospitalization, produce a disability at the time of discharge, or both. Used in this report,
complication does not refer to the sequelae of diseases, such as neuropathy as a complication
of diabetes. Throughout the report, sequelae is used to refer to these conditions.

Medical error. The failure of a planned action to be completed as intended (i.e., error of
execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).1 The definition
includes errors committed by any individual, or set of individuals, working in a health care
organization.5

Patient safety. Freedom from accidental injury, or avoiding injuries or harm to patients from
care that is intended to help them. Ensuring patient safety involves the establishment of
operational systems and processes that minimize the likelihood of errors and maximizes the
likelihood of intercepting them when they occur. 6

Patient safety indicators. Specific quality indicators which also reflect the quality of care inside
hospitals, but focus on aspects of patient safety. Specifically, PSIs screen for problems that
patients experience as a result of exposure to the healthcare system, and that are likely
amenable to prevention by changes at the system or provider level.

Preventable adverse event. An adverse event attributable to error is a preventable adverse

event.7 A condition for which reasonable steps may reduce (but not necessarily eliminate) the

4
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and
negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-
6.
5
Institute of Medicine, 2000.
6
Envisioning the National Health Care Quality Report. Washington, DC: Institute of Medicine; 2001.

7
Brennan et al., 1991.

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 risk of that complication occurring.

Quality. Quality of care is the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current professional
knowledge. In this definition, the term health services refers to a wide array of services that
affect health(and) applies to many types of health care practitioners (physicians, nurses, and
various other health professionals) and to all settings of care8

Quality indicators. Screening tools for the purpose of identifying potential areas of concern
regarding the quality of clinical care. For the purpose of this report, we focus on indicators that
reflect the quality of care inside hospitals. Quality indicators may assess any of the four system
components of health care quality, including patient safety (see below), effectiveness (i.e.,
providing services based on scientific knowledge to all who could benefit, and refraining from
providing services to those not likely to benefit), patient centeredness, and timeliness (i.e.,
minimizing unnecessary delays").9

Rate based indicators. Indicators for which the primary purpose is to identify the rate of a
complication rather than to identify specific cases.

While the definitions above are intended to distinguish events that are less preventable from
those that are more preventable, the difference is best described as a spectrum. To conceptualize this
spectrum, the project team developed the following three categories of conditions:

1. Conditions that could be either a comorbidity or a complication. Conditions considered comorbidities

(for example, congestive heart failure) are present on admission and are not caused by medical
management; rather, they are due to the patients underlying disease. It is extremely difficult to
distinguish complications from comorbidities for these conditions using administrative data. As a
result, these conditions were not considered in this report.

2. Conditions that are likely to reflect medical error. These conditions (for example, foreign body
accidentally left during a procedure) are likely to have been caused by medical error. Most of these
conditions appear infrequently in administrative data, and thus rates of events lack the precision to
allow for comparisons between providers. However, these conditions may be the subject of case-
finding indicators.

3. Conditions that conceivably, but not definitively reflect medical error. These conditions (for example,
postoperative DVT or PE) represent a spectrum of preventability between the previous two
categoriesfrom those that are mostly unpreventable to those that are mostly preventable. Because
of the uncertainty regarding the preventability of these conditions and the likely heterogeneity of
cases with the condition, indicators using these conditions are less useful as case-finding indicators.
However, examining the rate of these conditions may highlight potential areas of concern.

8
Measuring the Quality of Health Care: A statement of the National Roundtable on Healthcare Quality Division of
Healthcare Services: National Academy Press; 1999.
9
National Roundtable on Healthcare Quality, 1999.

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Evaluation Framework

To evaluate the soundness of each indicator, the project team applied the same framework as
was applied in the technical report10 for the Prevention Quality Indicators (PQIs) and Inpatient Quality
Indicators (IQIs). This included six areas of evidence:

Face validity. Does the indicator capture an aspect of quality that is widely regarded as important
and subject to provider or public health system control? Consensual validity expands face validity
beyond one person to the opinion of a panel of experts.

Precision. Is there a substantial amount of provider- or community-level variation that is not

attributable to random variation?

Minimum bias. Is there either little effect on the indicator of variations in patient disease severity and
comorbidities, or is it possible to apply risk adjustment and statistical methods to remove most or all
bias?

Construct validity. Does the indicator perform well in identifying true (or actual) quality of care
problems?

Fosters real quality improvement. Is the indicator insulated from perverse incentives for providers
to improve their reported performance by avoiding difficult or complex cases, or by other responses
that do not improve quality of care?

Application. Has the measure been used effectively in practice? Does it have potential for working
well with other indicators?

Face validity (consensual validity) was evaluated using a structured panel review, minimum bias was
explored empirically and briefly during the panel review, and construct validity was evaluated using the
limited literature available. A full discussion of this framework is available in the Stanford Technical
report.11

The relative importance of each of these evaluation areas may differ by individual PSIs..
Precision and minimum bias may be less important for indicators that are primarily designed to screen
only for medical error, since these events are relatively rare. In general, these indicators are better used
as case-finding indicators. For these indicators, comparisons between rates are less relevant. However,
for rate-based indicators, concerns of precision and minimum bias remain if indicators are used in any
comparison of rates (comparison to national averages, peer group, etc.).

Step 2: Search the Literature to Identify Potential PSIs

The literature searches performed in connection with assessing potential AHRQ QIs12 identified
many references relevant to potential PSIs. In addition, the project team performed electronic searches
for articles published before February 2002 followed by hand searching the bibliographies of identified
references. Members of the project team were queried to supplement this list, based on their personal

10
Davies S, Geppert J, McClellan M, McDonald KM, Romano PS, Shojania KG. Refinement of the HCUP Quality
Indicators. Technical Review Number 4. Rockville, MD: (Prepared by UCSF-Stanford Evidence-based Practice
Center under Contract No. 290-97-0013) Agency for Healthcare Research and Quality; 2001. Report No.: 01-0035.
11
Davies et al., 2001.
12
Davies et al., 2001.

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knowledge of recent work in the field. Because Iezzoni et al.s Complications Screening Program (CSP)13
included numerous candidate indicators, the team also performed an author search using her name.
Forthcoming articles and Federal reports in press, but not published, were also included when identified
through personal contacts.

The project team identified 326 articles from the Medline search. Articles were screened using
both the titles and abstracts. To qualify for abstraction, an article must have described, evaluated, or
validated a potential indicator of medical errors, patient safety, or potentially preventable complications
based on International Classification for Diseases - Ninth Revision - Clinical Modifications (ICD-9-CM)
coded administrative (hospital discharge or claims) data. Some indicators were also considered if they
appeared to be readily translated into ICD-9-CM, even if the original authors did not use ICD-9-CM codes.

This search was adapted slightly and repeated using the OVID interface with EMBASE14, limited
to articles published from January 1990 through the end of first quarter 2002. The EMBASE search
identified 463 references, and these articles were screened in the same manner. After elimination of
articles that had already been identified using Medline15 and the other approaches described above, only
nine additional articles met the criteria for abstraction.

Step 3: Develop a Candidate List of PSIs

The project team developed a candidate list of PSIs by first reviewing the literature, then selecting
a subset of indicators to undergo face validity testing by clinician panels.

Candidate List of PSIs

The literature search located relatively few patient safety indicators that could be defined using
unlinked administrative data. The majority of these indicators were from the Complications Screening
Program (CSP),16 which was developed to identify potentially preventable complications of adult medical
and surgical hospital care using commonly available administrative data. The algorithm uses discharge
abstract dataspecifically ICD-9-CM diagnosis and procedure codes, patient age, sex, diagnosis-related
group (DRG), and date of procedureto identify 28 complications that raise concern about the quality of
care based on the rate of such occurrences at individual hospitals. Each of the complications is applied to
some or all of the following specified risk pools separately: major surgery, minor surgery, invasive
cardiac procedure, endoscopy, medical patients, and all patients. In addition, specified inclusion and
exclusion criteria are applied to each complication to ensure that the complication developed in-hospital,
as opposed to being present on admission, and that the complication was potentially preventable.

Four later studies were designed to test criterion and construct validity by validating the data used
to construct CSP screens, validating the screens as a flag for actual quality problems, and validating the
replicability of hospital-level results using different data sources.17 18 19 20 These studies raised concerns

13
Iezzoni LI, Foley SM, Heeren T, Daley J, Duncan CC, Fisher ES, et al. A method for screening the quality of
hospital care using administrative data: preliminary validation results. QRB Qual Rev Bull 1992;18(11):361-71.
14
EMBASE. In. The Netherlands: Elsevier Science Publishers B.V.

15
MEDLINE [database online]. In. Bethesda (MD): National Library of Medicine.

16
Iezzoni et al., 1992.

17
Lawthers A, McCarthy E, Davis R, Peterson L, Palmer R, Iezzoni L. Identification of in-hospital complications from
claims data: is it valid? Medical Care 2000;38(8):785-795.
18
McCarthy EP, Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamael MB, et al. Does clinical evidence support

Version 2.1 9 Revision 1 (May 28, 2003)

about the validity of the CSP, because flagged cases for most indicators were no more likely than
unflagged controls to have suffered explicit process failures.

The project team also reviewed all ICD-9-CM codes implemented in or before 1999 that were
identified by AHRQ as possibly describing medical errors or reflecting the consequences of such errors.21
(This initial set of indicators is referred to as the Miller et al. indicators.) The project team added relevant
codes from the 2000 and 2001 revisions of ICD-9-CM and selected codes from the CSP, such as those
not clearly reflective of medical error, but representing a potentially preventable complication. This
process was guided principally by conceptual considerations. For example, codes for postoperative AMI
(an evaluated indicator that was not included in the final indicator set) were included in the evaluation set
since recent evidence suggests that AMI is a potentially preventable complication.22 A few codes were
also deleted from the initial list based on a review of ICD-9-CM coding guidelines, described in Coding
Clinics for ICD-9-CM and the American Hospital Associations ICD-9-CM Coding Handbook. For example,
the code 2593 for hypoglycemic coma specifically excludes patients with diabetes mellitus, the population
for which this complication is most preventable. This process of updating the Miller et al. PSIs resulted in
a list of over 200 ICD-9-CM codes (valid in 2001) potentially related to medical error.

Codes identified in the CSP and updated from the Miller et. al. PSIs were then grouped into
indicators. Where feasible, codes were compiled as they were in the CSP, or in some cases the Miller et
al. PSIs, depending on which grouping yielded more clinically homogeneous groups. In most cases the
resulting indicators were not identical to the CSP indicators, although they were closely related, as some
of the specific codes included in the original CSP had been eliminated after the teams review of coding
guidelines. The remaining codes were then incorporated into the most appropriate CSP-based indicator,
or were grouped into clinically meaningful concepts to define novel indicators. Exclusion criteria were
added based on CSP methods and clinical judgment. As a result, over 40 patient safety indicators were
defined that, while building on prior work, reflected significantly changed measures to focus more
narrowly on the most preventable complications.

Indicators were defined with both a numerator (complication of interest) and a denominator
(population at risk). Different patient subpopulations have inherently different risks for developing a
complication, with some patients having almost no risk. Thus, the denominator for each indicator
represents the specific population at risk. The intention was to restrict the complication (and consequently
the rate) to a more homogeneous population who are actually at risk for that complication. In general, the
population at risk corresponded to one risk pool (e.g., major surgery) from the CSP, if applicable, or was
defined more narrowly.

Subset Selection

After the project team developed a list of potential indicators, they selected a subset of indicators

ICD-9-CM diagnosis coding of complications? Med Care 2000;38(8);868-876.

19
Weingart SN, Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamel MB, et al. Use of administrative data to find
substandard care: validation of th complications screening program Med Care 2000;38(8):796-806.
20
Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamel MB, Mukamal K, et al. Does the Complications Screening
Program flag cases with process of care problems? Using explicit criteria to judge processes. Int J Qual Health Care
1999;11(2):107-18.
21
Miller M, Elixhauser A, Zhan C, Meyer G. Patient Safety Indicators: Using administrative data to identify potential
patient safety concerns. Health Services Research 2001;36(6 Part II):110-132.
22
Shojania KG, Duncan BW, MdDonald KM, Wachter RM. Making health care safer: A critical analysis of patient
safety practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California at San
Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). Rockville, MD: Agency for
Healthcare Research and Quality; 2001. Report No.: AHRQ Publication No. 01-E058.

Version 2.1 10 Revision 1 (May 28, 2003)

to undergo face validity testing by clinician panels, as described in Step 4. Two sources of information
guided the selection process.

First, validation data from previous studies were reviewed and thresholds were set for retaining
CSP-based indicators. Four studies were identified that evaluated the CSP indicators. Three of these
studies, examined the predictive value of each indicator in identifying a complication that occurred in-
hospital, regardless of whether this complication was due to medical error or was preventable. 23 24 25 In a
fourth study, nurses identified specific process failures that may have contributed to complications. In
order to be retained as a potential PSI, at least one of the first three studies needed to demonstrate a
positive predictive value of at least 75%, meaning that 3 out of 4 patients identified by the measure did
indeed have the complication of interest.26 In addition, the positive predictive value of a "process failure"
identified in the fourth study needed to reach or exceed 46%, which was the average rate for surgical
cases that were not flagged by any of the CSP indicators. As a result, only CSP-derived indicators that
were at least somewhat predictive of objectively defined process failures or medical errors were retained.

Second, specific changes to previous definitions or constructs of indicators fell into the following
general categories:

1. Changes to the denominator definitions (inclusion or exclusion criteria), intended to reduce bias
due to the inclusion of atypical patients or to improve generalizability to a broader set of patients
at risk.

2. Elimination of selected ICD-9-CM codes from numerator definitions, intended to focus attention
on more clinically significant complications or complications more likely to result from medical
errors.

3. Addition of selected ICD-9-CM codes to numerator definitions, intended to capture related

complications that could result from the same or similar medical errors.

4. Division of a single indicator into two or more related indicators, intended to create more clinically
meaningful and conceptually coherent indicators.

5. Stratification or adjustment by relevant patient characteristics, intended to reflect fundamental

clinical differences among procedures (e.g., vaginal delivery with or without instrumentation) and
the complications that result from them, or fundamental differences in patient risk (e.g., decubitus
ulcer in lower-risk versus high-risk patients).

A total of 34 indicators, intended to be applied to all age groups, were retained for face validity
testing by clinician panels. Because the primary intent in developing these indicators was to detect
potentially preventable complications related to health care exposure, the final definitions for this set of
indicators represented mostly new measures that built upon previous work.

Coding Review

Experts in ICD-9-CM codes reviewed each code for accuracy of capturing the complication and
population at risk. In some cases, additional codes or other refinements to the indicators were suggested
based on current coding guidelines.

23
Lawthers, et al., 2000.

24
McCarthy, et al., 2000.

25
Weingart et al., 2000.

26
Iezzoni et al., 1999.

Version 2.1 11 Revision 1 (May 28, 2003)

Step 4: Review the PSIs

The project team conducted a structured review of each indicator to evaluate the face validity
(from a clinical perspective) of the indicators. The methodology for the structured review was adapted
from the RAND/UCLA Appropriateness Method27 and consisted of an initial independent assessment of
each indicator by clinician panelists using an initial questionnaire, a conference call among all panelists,
followed by a final independent assessment by clinician panelists using the same questionnaire. The
review sought to establish consensual validity, which extends face validity from one expert to a panel of
experts who examine and rate the appropriateness of each item.28 The panel process served to refine
definitions of some indicators, add new measures, and dismiss indicators with major concerns from
further consideration.

Eight panels were formed: two panels examined complications of medical care indicators, three
panels examined surgical complications indicators, one panel assessed indicators related to procedural
complications, and two panels examined obstetric complications indicators.

Fifteen professional clinical organizations nominated a total of 162 clinicians to be panelists. To

be eligible to participate, nominees were required to spend at least 30% of their work time on patient care,
including hospitalized patients. Nominees were asked to provide information regarding their practice
characteristics, including specialty, subspecialty, and setting. Fifty-seven panelists were selected to
ensure that each panel had diverse membership in terms of practice characteristics and setting.

Initial Assessment of the Indicators

Panelists were presented with four or five indicators, including the standardized text used to
describe each ICD-9-CM code, the specific numeric code, exclusion and inclusion criteria, the clinical
rationale for the indicator, and the specification criteria. For each indicator, panelists completed a 10-item
questionnaire that evaluated the ability of the indicator to screen out conditions present on admission, the
potential preventability of the complication, and the ability of the indicator to identify medical error. In
addition, the questionnaire asked panelists to consider potential bias, reporting or charting problems,
potential for gaming the indicator, and adverse effects of implementing the indicator. Finally, the
questionnaire provided an opportunity for panelists to suggest changes to the indicator.

Conference Call Participation

After the panelists submitted the initial evaluation questionnaires, they participated in a 90-minute
conference call for their panel to discuss the indicators. In general, agenda items for the conference call
focused on points of disagreement among panelists. However, panelists were explicitly told that
consensus was not the goal of discussion. In some cases, panelists agreed on proposed changes to the
indicator definitions, and such consensus was noted and the definition was modified accordingly before
the final round of rating.

Panelists were prompted throughout the process to consider the appropriate population at risk for
each indicator (specifically inclusion and exclusion criteria) in addition to the complication of interest.
However, if panelists wished to discuss other aspects of the indicator, this discussion was allowed within
the time allotted for that indicator (approximately 15 minutes). If time remained at the end of a call, topics
that were not fully addressed previously were revisited.

Final Evaluation and Tabulation of Results

27
Fitch K, Bernstein J, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, et al. the RAND/UCLA Appropriateness
Method Users Manual: RAND; 2001.
28
Green L, Lewis F. measurement and Evaluation in Health Education and Health Promotion. Mountain View, CA:
Mayfield Publishing Company; 1998.

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 Following each conference call, the project team made changes to each indicator suggested by
panelists for changes that reached near consensus of the panelists. The indicators were then
redistributed to panelists with the questionnaires used in the initial evaluation. The reason for all each
indicator definition change was included, and panelists were asked to re-rate the indicator based on their
current opinion. They were asked to keep in mind the discussion during the conference call.

Results from the final evaluation questionnaire were used to calculate median scores from the 9-
point scale for each question and to categorize the degree of agreement among panelists. Median scores
determined the level of acceptability of the indicator, and dispersion of ratings across the panel for each
applicable question determined the agreement status. Therefore the median and agreement status were
independent measurements for each question. Six criteria were used to identify the panel opinions (i.e.,
median, agreement status category) on the following aspects of the indicator:

1. Overall usefulness of the indicator.

2. Likelihood that the indicator measures a complication and not a comorbidity (specifically, present
on admission).
3. Preventability of the complication.
4. Extent to which the complication is due to medical error.
5. Likelihood that the complication is charted given that it occurs.
6. Extent that the indicator is subject to bias (systematic differences, such as case mix that could
affect the indicator, in a way not related to quality of care).

The project team used the ratings of the overall appropriateness of each indicator to assess its
overall usefulness as a screen for potential patient safety problems. Indicators were triaged into three
sets: Accepted Indicators (described in this guide), Experimental Indicators, and Rejected Indicators.

Step 5: Evaluate the PSIs Using Empirical Analysis

The project team conducted empirical analyses to explore the frequency and variation of the
indicators, the potential bias, based on limited risk adjustment, and the relationship between indicators.
The data sources used in the empirical analyses were the 1997 Florida State Inpatient Database (SID) for
initial testing and development and the 1997 HCUP State Inpatient Database for 19 States (referred to in
this guide as the HCUP SID) for the final empirical analyses. The rates presented in the Detailed
Evidence Section of this guide, as well as the means and parameter reference files used by the PSI
software, reflect analyses of the 2000 HCUP SID for 29 states.

All potential indicators were examined empirically by developing and conducting statistical tests
for precision, bias, and relatedness of indicators. Three different estimates of hospital performance were
calculated for each indicator:

1. The raw indicator rate was calculated using the number of adverse events in the numerator divided
by the number of discharges in the population at risk by hospital.

2. The raw indicator was adjusted to account for differences among hospitals in age, gender, modified
DRG, and comorbidities.

Adjacent DRG categories that were separated by the presence or absence of comorbidities or
complications were collapsed to avoid adjusting for the complication being measured. Most of
the super-Major Diagnostic Category (MDC) DRG categories were excluded for the same reason.

APR-DRG risk adjustment was not implemented because removing applicable complications from
each indicator was beyond the scope of this project.

The ICD-9-CM codes used to define comorbidity categories were modified to exclude conditions
likely to represent potentially preventable complications in certain settings.

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 Acute on chronic comorbidities were captured so that some patients with especially severe
comorbidities would not be mislabeled as not having conditions of interest.

Comorbidities in obstetric patients were added.

3. Multivariate signal extraction methods were applied to adjust for reliability by estimating the amount of
noise (i.e., variation due to random error) relative to the amount of signal (i.e., systematic variation
in hospital performance or reliability) for each indicator.

Similar reliability adjustment has been used in the literature for similar purposes.29 30 The project team
constructed a set of statistical tests to examine precision, bias, and relatedness of indicators for all
accepted hospital-level indicators, and precision and bias for all accepted area-level indicators. It should
be noted that rates based on fewer than 30 cases in the numerator or the denominator are not reported.
This exclusion rule serves two purposes:

1. It eliminates unstable estimates based on too few cases.

2. It helps protect the identities of hospitals and patients.

A detailed description of the methodology is included in Appendix B.

29
Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual
physician report cards for assessing the costs and quality of care of a chronic disease JAMA 1999;281(22):2098-
105.
30
Christiansen CL, Morris CN. Improving the statistical approach to health care provider profiling. Ann Intern Med
1997;127(8 Pt 2):764-8.

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Summary Evidence on the Patient Safety Indicators

This project took a four-pronged approach to the identification, development, and evaluation of
PSIs that included use of literature, clinician panels, expert coders, and empirical analyses. The literature
review and the findings from the clinical panels combined with data analysis provide evidence to suggest
that a number of discharge-based PSIs may be useful screens for organizations, purchasers, and
policymakers to identify safety problems at the hospital level, as well as to document systematic area-
level differences in patient safety problems.

Most adverse events identified by the PSIs have a variety of causes in addition to potential
medical error leading to the adverse event, including underlying patient health and factors that do not vary
systematically. Clinician panelists rated only two of the accepted indicators as very likely to reflect
medical error: (1) transfusion reaction and (2) foreign body left in during a procedure. These indicators
proved to be very rare, with less than 1 per 10,000 cases at risk.

Table 1 summarizes the results of the literature review, clinician panels, and empirical analyses
on the hospital-level PSIs. The table lists each indicator, provides its definition, identifies any concerns
about its validity based on the clinician panels, and summarizes the strength of evidence in the literature
for each indicator.

The following notes about some of the terms in the table are intended to help the reader
understand the context in which they are used.

Validity Concerns. The following concerns, raised during our panel review, are listed if they affect the
validity of the particular indicator:

Rare This indicator is relatively rare and may not have adequate statistical power for some
providers.
Condition definition varies This indicator includes conditions for which diagnosis may be
subjective, depending on the threshold of the physician, and patients with the same clinical state
may not have the same diagnosis.
Underreporting or screening Conditions included in this indicator may not be systematically
reported (leading to an artificially low rate) or may be routinely screened for (leading to a higher
rate in facilities that screen).
Adverse consequences Use of this indicator may have undesirable effects, such as increasing
inappropriate antibiotic use.
Stratification suggested This indicator includes some high risk patient groups and stratification is
recommended when examining rates,
Unclear preventability As compared to other PSIs, the conditions included in this indicator may
be less preventable by the health system.
Heterogeneous severity This indicator includes codes that encompass several levels of severity
of a condition that cannot be ascertained by the codes.
Case mix bias This indicator was felt to be particularly subject to systematic bias, and DRG and
comorbidity risk adjustment may not adequately address the concern.
Denominator unspecific The denominator for this indicator is less than ideal, because the true
population at risk could not be identified using ICD-9-CM codes. Some patients are likely
included who are not truly at risk, or some patients who are at risk are not included.

Empirical Performance. The performance of each indicator is measured for the following:

Rate The rate measures the number of adverse events per 1,000 population at risk. Rates
represent the average rate of the indicator for a nationwide sample of hospitals.
Deviation Standard deviation is an estimate of systematic variation. For the PSIs, standard
deviation is reported between providers.
Bias Bias represents the degree to which the results may be influenced by outside factors. Bias

Version 2.1 15 Revision 1 (May 28, 2003)

 ratings are based on a series of tests of bias using DRG and comorbidity risk adjustment. Those
indicators flagged with X+ demonstrated substantial bias and should be risk adjusted. Those
indicators flagged with X also demonstrated some bias. Those without a flag did not demonstrate
substantial bias in empirical tests, but may nonetheless be substantially biased in a manner not
detectable by the bias tests. Those marked with N/A did not undergo empirical testing of bias due
to lack of systematic variation.

Strength of Evidence. The following key findings represent a review of the limited literature assessing
the validity of the indicators:

Coding Sensitivity is the proportion of patients who suffered an adverse event, based on detailed
chart review or prospective data collection, for whom that event was coded on a discharge
abstract or Medicare claim. Predictive value is the proportion of patients with a coded adverse
event who were confirmed as having suffered that event, based on detailed chart review or
prospective data collection.
Construct, explicit process Adherence to specific, evidence-based or expert-endorsed
processes of care, such as appropriate use of diagnostic modalities and effective therapies. The
construct is that hospitals that provide better processes of care should experience fewer adverse
events.
Construct, implicit process Adherence to the standard of care for similar patients, based on
global assessment of quality by physician chart reviewers. The construct is that hospitals that
provide better overall care should experience fewer adverse events.
Construct, staffing The construct is that hospitals that offer more nursing hours per patient day,
better nursing skill mix, better physician skill mix, or more experienced physicians should have
fewer adverse events.
Published evidence suggests that the indicator lacks validity in this domain (i.e., less than 50%
sensitivity or predictive value; explicit or implicit process failure rates no more frequent than
among control patients).

The following distinctions were used to summarize the strength of the published evidence for
each indicator:
0 No published evidence regarding this domain of validity.
Published evidence suggests that the indicator may be valid in this domain, but different
studies offer conflicting results (although study quality may account for these conflicts).
+ Published evidence suggests that the indicator is valid, or is likely to be valid, in this domain
(i.e., one favorable study).
++ There is strong evidence supporting the validity of this indicator in this domain (i.e., multiple
studies with consistent results, or studies showing both high sensitivity and high predictive value).
When content validity is exceptionally high, as for transfusion reaction or iatrogenic
pneumothorax, construct validity becomes less important.

A complete description of each PSI is included later in the guide under Detailed Evidence for
Patient Safety Indicators and in Appendix A. Details on the empirical methods can be found in Appendix
B.

Version 2.1 16 Revision 1 (May 28, 2003)

Table 1. AHRQ Hospital-Level Patient Safety Indicators

Definition Validity Concerns Empirical Strength of

Performance Evidence
Complications Cases of anesthetic Condition definition Rate = 0.60 0 Coding
of anesthesia overdose, reaction, or varies Deviation = 1.72 0 Explicit Process
endotrachial tube Bias = Not 0 Implicit Process
misplacement per 1,000 Underreporting or detected
c
0 Staffing
surgery discharges. screening
Excludes codes for drug Denominator
use and self-inflicted injury. unspecific
Death in low In-hospital deaths per Heterogeneous Rate = 2.44 + Coding
mortality DRGs 1,000 patients in DRGs severity Deviation = 30.6 0 Explicit Process
with less than 0.5% Bias = X+ + Implicit Process
a
mortality. Excludes 0 Staffing
trauma,
immunocompromised, and
cancer patients.
Decubitus Cases of decubitus ulcer Underreporting or Rate = 23.9 Coding
ulcer per 1,000 discharges with a screening Deviation = 21.6 0 Explicit Process
length of stay of 5 or more Bias = X+ 0 Implicit Process
days. Excludes patients Heterogeneous Staffing
with paralysis or in MDC 9, severity
obstetrical patients in MDC Case mix bias
14, and patients admitted
from a long-term care
facility.
Failure to Deaths per 1,000 patients Adverse Rate = 129.4 + Coding
rescue having developed specified consequences Deviation = 87.1 0 Explicit Process
complications of care Bias = X+ 0 Implicit Process
during hospitalization. Stratification ++ Staffing
Excludes patients age 75 suggested
and older, neonates in Unclear preventability
MDC 15, patients admitted
from long-term care facility Heterogeneous
and patients transferred to severity
or from other acute care
facility.
Foreign body Discharges with foreign Rare Rate = 0.07 0 Coding
left during body accidentally left in Deviation = 0.17 0 Explicit Process
procedure during procedure per 1,000 Stratification Bias = N/A 0 Implicit Process
discharges suggested 0 Staffing
Denominator
unspecific
Iatrogenic Cases of iatrogenic Denominator Rate = 0.63 0 Coding
pneumothorax pneumothorax per 1,000 unspecific Deviation = 0.71 0 Explicit Process
discharges. Excludes Bias = X 0 Implicit Process
trauma, thoracic surgery, 0 Staffing
lung or pleural biopsy, or
cardiac surgery patients,
and obstetrical patients in
MDC 14.

Version 2.1 17 Revision 1 (May 28, 2003)

 Definition Validity Concerns Empirical Strength of
Performance Evidence
Selected Cases of secondary ICD-9- Underreporting or Rate = 1.50 0 Coding
infections due CM codes 9993 or 00662 screening Deviation = 3.30 0 Explicit Process
to medical care per 1,000 discharges. Bias = X 0 Implicit Process
Excludes patients with Adverse 0 Staffing
immunocompromised state consequences
or cancer.
Postoperative Cases of hematoma or Stratification Rate = 1.26 Coding
hemorrhage or hemorrhage requiring a suggested Deviation = 2.11 Explicit Process
hematoma procedure per 1,000 Bias = Not + Implicit Process
surgical discharges. Case mix bias detected 0 Staffing
Excludes obstetrical Denominator
patients in MDC 14. unspecific
Postoperative Cases of in-hospital hip Case mix bias Rate = 1.33 + Coding
hip fracture fracture per 1,000 surgical Deviation = 5.98 + Explicit Process
discharges. Excludes Denominator Bias = X + Implicit Process
patients in MDC 8, with unspecific 0 Staffing
conditions suggesting
fracture present on
admission and obstetrical
patients in MDC 14.
Postoperative Cases of specified Condition definition Rate = 0.78 Coding
physiologic physiological or metabolic varies Deviation = 10.3 0 Explicit Process
and metabolic derangement per 1,000 Bias = X 0 Implicit Process
derangement elective surgical Staffing
discharges. Excludes
patients with principal
diagnosis of diabetes and
with diagnoses suggesting
increased susceptibility to
derangement. Excludes
obstetric admissions.
Postoperative Cases of deep vein Underreporting or Rate = 9.30 + Coding
PE or DVT thrombosis or pulmonary screening Deviation = 32.8 + Explicit Process
embolism per 1,000 Bias = X+ + Implicit Process
surgical discharges. Stratification Staffing
Excludes obstetric patients. suggested

Postoperative Cases of acute respiratory Unclear preventability Rate = 3.47 + Coding

respiratory failure per 1,000 elective Deviation = 12.1 Explicit Process
failure surgical discharges. Case mix bias Bias = X+ + Implicit Process
Excludes MDC 4 and 5 and Staffing
obstetric admissions.
Postoperative Cases of sepsis per 1,000 Condition definition Rate = 11.8 Coding
sepsis elective surgery patients, varies Deviation = 39.8 0 Explicit Process
with length of stay more Bias = X+ 0 Implicit Process
than 3 days. Excludes Adverse Staffing
principal diagnosis of consequences
infection, or any diagnosis
of immunocompromised
state or cancer, and
obstetric admissions.

Version 2.1 18 Revision 1 (May 28, 2003)

 Definition Validity Concerns Empirical Strength of
Performance Evidence
Postoperative Cases of reclosure of Case mix bias Rate = 1.95 0 Coding
wound postoperative disruption of Deviation = 4.90 0 Explicit Process
dehiscence abdominal wall per 1,000 Bias = X 0 Implicit Process
cases of abdominopelvic 0 Staffing
surgery. Excludes obstetric
admissions.
Accidental Cases of technical difficulty Underreporting or Rate = 2.45 Coding
puncture or (e.g., accidental cut or screening Deviation = 2.58 0 Explicit Process
laceration laceration during Bias = X+ 0 Implicit Process
procedure) per 1,000 Unclear preventability 0 Staffing
discharges. Excludes
obstetric admissions.
Transfusion Cases of transfusion Rare Rate = 0.005 0 Coding
reaction reaction per 1,000 Deviation = 0.106 0 Explicit Process
discharges. Stratification Bias = N/A 0 Implicit Process
suggested 0 Staffing
Birth trauma Cases of birth trauma per Condition definition Rate = 5.61 Coding
injury to 1,000 liveborn births. varies Deviation = 19.9 0 Explicit Process
neonate Excludes some preterm Bias = N/A 0 Implicit Process
infants and infants with Unclear preventability 0 Staffing
osteogenic imperfecta. Heterogeneous
severity
Obstetric Cases of obstetric trauma Unclear preventability Rate = 5.60 + Coding
trauma (4th degree lacerations, Deviation = 9.99 0 Explicit Process
Cesarean other obstetric lacerations) Case mix bias Bias = N/A 0 Implicit Process
delivery per 1,000 Cesarean 0 Staffing
deliveries.
Obstetric Cases of obstetric trauma Unclear preventability Rate = 218.6 + Coding
th
traumavagin (4 degree lacerations, Deviation = 167.1 0 Explicit Process
al delivery with other obstetric lacerations) Case mix bias Bias = N/A 0 Implicit Process
instrument per 1,000 instrument- 0 Staffing
assisted vaginal deliveries.
Obstetric Cases of obstetric trauma Unclear preventability Rate = 80.8 + Coding
traumavagin (4th degree lacerations, Deviation = 58.4 0 Explicit Process
al delivery other obstetric lacerations) Case mix bias Bias = N/A 0 Implicit Process
without per 1,000 vaginal deliveries 0 Staffing
instrument without instrument
assistance.

a
DRGs that are divided into with complications and comorbidities and without complications and comorbidities are
only included if both divisions have mortality rates below 0.5%.

Limitations in Using the PSIs

Many important concerns cannot currently be monitored well using administrative data, such as
adverse drug events, and using these data tends to favor specific types of indicators. For example, the
PSIs evaluated in this report contain a large proportion of surgical indicators, rather than medical or
psychiatric, because medical complications are often difficult to distinguish from comorbidities that are
present on admission. In addition, medical populations tend to be more heterogeneous than surgical,
especially elective surgical populations, making it difficult to account for case-mix. Panelists often
expressed that indicators were more applicable to patient safety when limited to elective surgical
admissions. However, the careful use of administrative data holds promise for screening to target further

Version 2.1 19 Revision 1 (May 28, 2003)

data collection and analysis. The ability to assess all patients at risk for a particular patient safety
problem, along with the relative low cost, are particular strengths of these data sets.

Two broad areas of concern also hold true for these data sets.

1. Questions about the clinical accuracy of discharge-based diagnosis coding lead to concerns about
the interpretation of reported diagnoses that may represent safety problems. Specifically:

Administrative data are unlikely to capture all cases of a complication, regardless of the
preventability, without false positives and false negatives (sensitivity and specificity).

When the codes are accurate in defining an event, the clinical vagueness inherent in the
description of the code itself (e.g., hypotension), may lead to a highly heterogeneous pool of
clinical states represented by that code.

Incomplete reporting is an issue in the accuracy of any data source used for identifying patient
safety problems, as medical providers might fear adverse consequences as a result of full
disclosure in potentially public records such as discharge abstracts.

2. The information about the ability of these data to distinguish adverse events in which no error
occurred from true medical errors is limited. A number of factorssuch as the heterogeneity of
clinical conditions included in some codes, lack of information about event timing available in these
data sets, and limited clinical detail for risk adjustmentcontribute to the difficulty in identifying
complications that represent medical error or may be at least in some part preventable.

These factors may exist for other sources of patient safety data as well. For example, they have been
raised in the context of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
implementation of a sentinel event program geared at identifying serious adverse events that may be
related to underlying safety problems.

Further Research on PSIs

The initial validation evaluations reviewed and performed for the PSIs leave substantial room for
further research with detailed chart data and other data sources. Future validation work should focus on
the following:

The sensitivity and specificity of these indicators in detecting the occurrence of a complication.
The extent to which failures in processes of care at the system or individual level are detected using
these indicators.
The relationship of these indicators with other measures of quality, such as mortality.
Further explorations of bias and risk adjustment.

Enhancements to administrative data are worth exploring in the context of further validation studies that
use data from other sources. For example, as with other quality indicators, the addition of timing variables
may prove particularly useful in identifying whether a complication was present on admission, or whether
it occurred during the hospitalization. While some of the complications that are present on admission may
indeed reflect adverse events of care in a previous hospitalization or outpatient care, many may reflect
comorbidities instead of complications. A second example arealinking hospital data over time and with
outpatient data and other hospitalizationswould allow inclusion of complications that occur after
discharge and likely would increase the sensitivity of the PSIs.

Use of External Cause-of-Injury Codes

Version 2.1 20 Revision 1 (May 28, 2003)

 Several of the PSIs are based on capturing external cause-of-injury (e-code) data. These codes
are used to classify environmental events, circumstances, and conditions as the cause of injury,
poisoning, or other adverse events. External cause-of-injury codes are critical to evaluate population-
based, cause-specific data on nonfatal injuries at the state and local levels. However, not all states
collect this information in their hospital discharge data programs nor do all state uniform billing
committees require use of e-codes. Users of the PSIs should be knowledgeable of the e-code
requirements and practices of hospitals represented in the input data file. The table below provides a
summary of the PSIs that are dependent on e-codes for their definition (required), the PSIs that use e-
codes within their definition, and the PSIs that do not use any e-codes in their definition. If use of e-codes
is not mandated or coding may be highly variable across hospitals, the PSIs that are dependent upon e-
codes should not be used and the PSIs that include e-codes in their definition should be used with
caution.

Indicator
Number
Indicator Name Use of External Cause-of-Injury Codes
(used in
software)
15 & 25 Accidental puncture or laceration Required. Used in both the numerator and
denominator definitions.
17 Birth trauma Not used.
1 Complications of anesthesia Required. Used in the numerator definition.
2 Death in low mortality DRGs Not used.
3 Decubitus ulcer Not used.
4 Failure to rescue Not used.
5 & 21 Foreign body left during Required. Used in the numerator definition
procedure although the other ICD-9 CM codes may capture
the same information.
6 & 22 Iatrogenic pneumothorax Not used.
20 Obstetric trauma cesarean Not used.
section
18 Obstetric trauma vaginal with Not used.
instrument
19 Obstetric trauma vaginal without Not used.
instrument
9 Post-operative hemorrhage or Not used.
hematoma
8 Post-operative hip fracture Used as exclusion criteria in denominator
population.
10 Post-operative physiologic and Not used.
metabolic derangements
12 Post-operative pulmonary Not used.
embolism or deep vein
thrombosis
11 Post-operative respiratory failure Not used.
13 Post-operative sepsis Not used.
14 & 24 Post-operative wound dehiscence Not used.
7 & 23 Selected infections due to Not used.
medical care
16 & 26 Transfusion reaction Required. Used in the numerator definition
although the other ICD-9 CM codes may capture
the same information.

Version 2.1 21 Revision 1 (May 28, 2003)

Detailed Evidence for Patient Safety Indicators
This section provides an abbreviated presentation of the details of the literature review and the
empirical evaluation for each PSI, including:

The definition of the indicator

The outcome of interest (or numerator)
The population at risk (or denominator)
The type of indicator
The measures of empirical performance. Rates are per 1,000 qualifying discharges, rather than the
average hospital rates reported in the previous table.

The two-page descriptions for each indicator also include a more detailed discussion of the panel review,
the literature review, the source of the indicator, and the results of the empirical analysis, including
information related to adjustments to increase the robustness of the rates:

Reliability. Statistics on the signal standard deviation, signal share, and signal ratio were used to
examine the effect of the reliability adjustment. Multivariate methods were applied to most of the
indicators, and overall the reliability adjustment reduced the hospital-level variation dramatically. In
general, indicators with higher rates tend to perform better on tests of reliability, as a result, obstetric
indicators with high rates tend to do very well relative to other indicators.

Bias. The effect of age, gender, DRG, and comorbidity risk adjustment on the relative ranking of
hospitals compared to no risk adjustment was assessed, if applicable. The presence of high bias
suggests that risk adjustment, using administrative data elements, is necessary to interpret hospital-
level differences in the rates of these indicators.

A full report on the literature review and empirical evaluation can be found in Evidence Report for
Measures of patient Safety Based on Hospital Administrative Data The Patient Safety Indicators by the
UCSF-Stanford EPC, available at http:www.qualityindicators.ahrq.gov/. Detailed coding information
for each PSI is provided in Appendix A.

The software manual Patient Safety Indicators: SAS Software Documentation, Version 2.1 (also available
at http:www.qualityindicators.ahrq.gov) provides detailed instructions on how to use the PSI software
including data preparation, calculation of the PSI rates, and interpretation of output. All hospital level
indicators are expressed as rates per 1,000 discharges. To obtain the standardized rate for each
hospital level PSIs, the output of the software should be multiplied by 1,000. The area level indicators are
expressed as rates per 100,000 population. To obtain the standardized area rate for each area level
PSIs, the output of the software should be multiplied by 100,000.

Version 2.1 22 Revision 1 (May 28, 2003)

Complications of Anesthesia

Definition Cases of anesthetic overdose, reaction, or endotrachial tube misplacement

per 1,000 surgery discharges.
Numerator Discharges with ICD-9-CM diagnosis codes for anesthesia complications in
any secondary diagnosis field per 1,000 discharges.
Denominator All surgical discharges defined by specific DRGs.
Exclude patients with codes for poisoning due to anesthetics (E8551, 9681-
4, 9687) and any diagnosis code for active drug dependence, active non-
dependent abuse of drugs, or self-inflicted injury.
Type of Indicator Hospital level
Empirical Performance Rate: 0.55 per 1,000 population at risk
Bias: Not detected, but may be biased in a way undetectable by empirical
tests
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary eliminate the chance that these codes represent

intentional or accidental overdose on the part of
This indicator is intended to capture cases the patient, it should eliminate many of these
flagged by external cause-of-injury codes (e- cases.
codes) and complications codes for adverse
effects from the administration of therapeutic Literature Review
drugs, as well as the overdose of anesthetic
agents used primarily in therapeutic settings. The literature review focused on the validity of
complication indicators based on ICD-9-CM
Panel Review diagnosis or procedure codes. Results of the
literature review indicate no published evidence
Panelists had concerns about the frequency of for the sensitivity or predictive value of this
coding of these complications, especially since indicator based on detailed chart review or
the use of e-codes is considered voluntary and prospective data collection. Sensitivity is the
appears to vary widely among providers. proportion of the patients who suffered an
Plausibly, a reaction may be described without adverse event for whom that event was coded
attributing it to anesthetic. Another concern is on a discharge abstract or Medicare claim.
that some of these cases would be present on Predictive value is the proportion of patients with
admission (e.g., due to recreational drug use). a coded adverse event who were confirmed as
having suffered that event.
Panelists expressed concern about the events
that would be assigned to the code for incorrect The project team found no published evidence
placement of endotrachial tube. They noted that for this indicator that supports the following
true misplacement does represent medical error, constructs: (1) that hospitals that provide better
but they were skeptical about whether this code processes of care experience fewer adverse
would be limited to those situations. events; (2) that hospitals that provide better
overall care experience fewer adverse events;
Ideally, this indicator would be used with a and (3) that hospitals that offer more nursing
coding designation that distinguishes conditions hours per patient day, better nursing skill mix,
present on admission from those that develop better physician skill mix, or more experienced
in-hospital. However, this is not available in the physicians have fewer adverse events.
administrative data used to define this indicator,
and so this concern was addressed by Empirical Analysis
eliminating codes for drugs that are commonly The project team conducted extensive empirical
used as recreational drugs. While this does not analyses on the PSIs. Complications of

Version 2.1 23 Revision 1 (May 28, 2003)

anesthesia generally performs well on several muscle relaxants and accidental poisoning by
different dimensions, including reliability, bias, nitrogen oxides, which were omitted from this
relatedness of indicators, and persistence over PSI. Their definition excludes other codes
time. included in the PSI, namely, poisoning by other
and unspecified general anesthetics and
Reliability. The signal ratiomeasured by the external cause of injury codes for endotracheal
proportion of the total variation across hospitals tube wrongly place during anesthetic procedure
that is truly related to systematic differences and adverse effects of anesthetics in therapeutic
(signal) in hospital performance rather than use.
random variation (noise)is 75.7%, suggesting
that observed differences in risk-adjusted rates
likely reflect true differences across hospitals.

The signal standard deviation for this indicator is

0.00187, indicating that the systematic
differences (signal) among hospitals is lower
than many indicators and less likely associated
with hospital characteristics. The signal share is
0.00563, and is also lower than many indicators.
The signal share is a measure of the share of
total variation (hospital and patient) accounted
for by hospitals. The lower the share, the less
important the hospital in accounting for the rate
and the more important other potential factors
(e.g., patient characteristics).

Minimum bias. The project team assessed the

effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
compared to no risk adjustment. They
measured (1) the impact of adjustment on the
assessment of relative hospital performance, (2)
the relative importance of the adjustment, (3) the
impact on hospitals with the highest and lowest
rates, and (4) the impact throughout the
distribution. The detected bias for
Complications of anesthesia is low, indicating
that the measures are likely not biased based on
the characteristics observed. (It is possible that
characteristics that are not observed using
administrative data may be related to the
patients risk of experiencing an adverse event.)

Source

A subset of this indicator was originally

proposed by Iezzoni et al.31 as part of
Complications Screening Program (CSP) (CSP
21, Complications relating to anesthetic agents
and other CNS depressants) Their definition
also includes poisoning due to centrally acting

31
Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-
15.

Version 2.1 24 Revision 1 (May 28, 2003)

Death in Low-Mortality DRGs

Definition In-hospital deaths per 1,000 patients in DRGs with less than 0.5% mortality.
Numerator Discharges with disposition of deceased per 1,000 population at risk.
Denominator Patients in DRGs with less than 0.5% mortality rate, based on NIS 1997
low-mortality DRG. If a DRG is divided into without/with complications,
both DRGs must have mortality rates below 0.5% to qualify for inclusion.
Exclude patients with any code for trauma, immunocompromised state, or
cancer.
Type of Indicator Hospital level
Empirical Performance Rate: 0.66 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary Literature Review

This indicator is intended to identify in-hospital Based on two-stage implicit review of randomly
deaths in patients unlikely to die during selected deaths, Hannan et al. found that
hospitalization. The underlying assumption is patients in low-mortality DRGs (<0.5%) were 5.2
that when patients admitted for an extremely times more likely than all other patients who died
low-mortality condition or procedure die, a health (9.8% versus 1.7%) to have received care that
care error is more likely to be responsible. departed from professionally recognized
Patients experiencing trauma or having an standards, after adjusting for patient
immunocompromised state or cancer are demographic, geographic, and hospital
excluded, as these patients have higher non- characteristics.32 In 15 of these 26 cases (58%)
preventable mortality. of substandard care, the patients death was
attributed at least partially to that care. The
Panel Review association with substandard care was stronger
for the DRG-based definition of this indicator
The overall usefulness of this indicator was than for the procedure-based definition (5.7%
rated as favorable by panelists. Because the versus 1.7%, OR=3.2). The project team was
denominator includes many heterogeneous unable to find other evidence on the validity of
patients cared for by different services, this this indicator.
indicator should be stratified by DRG type (i.e.,
medical, surgical, psychiatric, obstetric, Empirical Analysis
pediatric) when used as an indicator of quality.
The project team conducted extensive empirical
Panelists noted that hospital case-mix may analyses on the PSIs. Death in low-mortality
affect the rate of death in low mortality DRGs, DRGs generally performs well on several
and that patients referred from skilled nursing different dimensions, including reliability, bias,
facilities, those with certain comorbidities, and relatedness of indicators, and persistence over
older patients may be at higher risk of dying. time.
They advocated risk adjustment for
comorbidities and age. Reliability. The signal ratiomeasured by the
proportion of the total variation across hospitals
Panelists advocated that this indicator not be that is truly related to systematic differences
subject to public reporting because of the
32
potential bias and questions about the extent of Hannan EL, Bernard HR, ODonnell JF, Kilburn H,
preventability. Jr. A methodology for targeting hospital cases for
quality of care record reviews. Am J Public Health
1989;79(4):430-6.
Version 2.1 25 Revision 1 (May 28, 2003)
(signal) in hospital performance rather than
random variation (noise)is high, relative to
other indicators, at 94.2%, suggesting that
observed differences in risk-adjusted rates likely
reflect true differences across hospitals.

The signal standard deviation for this indicator is

lower than many indicators, at 0.00439,
indicating that the systematic differences (signal)
among hospitals is low and less likely
associated with hospital characteristics. The
signal share is high, relative to other indicators,
at 0.04237. The signal share is a measure of
the share of total variation (hospital and patient)
accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
the rate and the more important other potential
factors (e.g., patient characteristics).

Minimum bias. The project team assessed the

effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
compared to no risk adjustment. They
measured (1) the impact of adjustment on the
assessment of relative hospital performance, (2)
the relative importance of the adjustment, (3) the
impact on hospitals with the highest and lowest
rates, and (4) the impact throughout the
distribution. The detected bias for Death in low-
mortality DRGs is high, indicating that the
measures are biased based on the
characteristics observed. (It is possible that
characteristics that are not observed using
administrative data may be related to the
patients risk of experiencing an adverse event.)
Risk adjustment is important for this indicator.

Source

This indicator was originally proposed by

Hannan et al. as a criterion for targeting cases
that would have a higher percentage of quality of
care problems than cases without the criterion,
as judged by medical record review.33 An
alternative form of this indicator focused on
primary surgical procedures, rather than
DRGs, with less than 0.5% inpatient mortality.

33
Hannan et al. 1989.

Version 2.1 26 Revision 1 (May 28, 2003)

Decubitus Ulcer

Definition Cases of decubitus ulcer per 1,000 discharges with a length of stay greater
than 4 days.
Numerator Discharges with ICD-9-CM code of 7070 in any secondary diagnosis field
per 1,000 discharges.
Denominator All medical and surgical discharges defined by specific DRGs.
Include only patients with a length of stay of 5 or more days.
Exclude patients in MDC-9 or patients with any diagnosis of hemiplegia,
paraplegia, or quadriplegia.
Exclude obstetrical patients in MDC 14.
Exclude patients admitted from a long-term care facility.
Type of Indicator Hospital level
Empirical Performance Rate: 22.7 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary which may cause this indicator to be somewhat

biased.
This indicator is intended to flag cases of in-
hospital decubitus ulcers. Its definition is limited This indicator includes pediatric patients.
to decubitus ulcer as a secondary diagnosis to Pressure sores are very unusual in children,
better screen out cases that may be present on except among the most critically ill children (who
admission. In addition, this indicator excludes may be paralyzed to improve ventilator
patients who have a length of stay of 4 days or management) and children with chronic
less, as it is unlikely that a decubitus ulcer would neurological problems. Age stratification is
develop within this period of time. Finally, this recommended.
indicator excludes patients who are particularly
susceptible to decubitus ulcer, namely patients Literature Review
with major skin disorders (MDC 9) and paralysis.
Coding validity. No evidence on validity is
Panel Review available from CSP studies. Geraci et al.
confirmed only 2 of 9 episodes of pressure
The overall usefulness of this indicator was ulcers reported on discharge abstracts of
rated as very favorable by panelists. Concerns Veterans Affairs (VA) patients hospitalized in
regarding the systematic screening for ulcers 1987-89 for congestive heart failure (CHF),
and reliability of coding, especially for early chronic obstructive pulmonary disease (COPD),
stage ulcers, brought into question that or diabetes.34 The sensitivity for a nosocomial
assertion. Therefore, this indicator appears to be ulcer was 40%. Among Medicare hip fracture
best used as a rate-based indicator. Panelists patients, Keeler et al. confirmed 6 of 9 reported
suggested that patients admitted from a long- pressure ulcers, but failed to ascertain 89
term care facility be excluded, as these patients
may have an increased risk of having decubiti
34
present on admission. Geraci JM, Ashton CM, Kuykendall DH, Johnson
ML, Wu L. International Classification of Diseases, 9th
Panelists noted that hospitals that routinely Revision, Clinical Modification codes in discharge
abstracts are poor measures of complication
screen for decubitus ulcers as part of a quality
occurrence in medical inpatients. Med Care
improvement program might have an artificially 1997;35(6):589-602.
high rate of ulcers compared to other hospitals,

Version 2.1 27 Revision 1 (May 28, 2003)

additional cases (6% sensitivity) using ICD-9- observed differences in risk-adjusted rates likely
CM codes.35 In the largest study to date, reflect true differences across hospitals.
Berlowitz et al. found that the sensitivity of a
discharge diagnosis of pressure ulcer among all The signal standard deviation for this indicator is
patients transferred from VA hospitals to VA lower than many indicators, at 0.0147, indicating
nursing homes in 1996 was 31% overall, or 54% that the systematic differences (signal) among
for stage IV (deep) ulcers.36 The overall hospitals is low and less likely associated with
sensitivity increased modestly since 1992 hospital characteristics. The signal share is
(26.0%), and was slightly but statistically lower than many indicators, at 0.01067. The
significantly better among medical patients than signal share is a measure of the share of total
among surgical patients (33% versus 26%). variation (hospital and patient) accounted for by
hospitals. The lower the share, the less
Construct validity. Needleman and Buerhaus important the hospital in accounting for the rate
found that nurse staffing was inconsistently and the more important other potential factors
associated with the occurrence of pressure (e.g., patient characteristics).
ulcers among medical patients, and was
independent of pressure ulcers among major Minimum bias. The project team assessed the
surgery patients.37 As was expected, nursing effect of age, gender, DRG, and comorbidity risk
skill mix (RN hours/licensed nurse hours) was adjustment on the relative ranking of hospitals
significantly associated with the pressure ulcer compared to no risk adjustment. They
rate.38 Total licensed nurse hours per acuity- measured (1) the impact of adjustment on the
adjusted patient day were inconsistently assessment of relative hospital performance, (2)
associated with the rate of pressure ulcers. the relative importance of the adjustment, (3) the
impact on hospitals with the highest and lowest
Empirical Analysis rates, and (4) the impact throughout the
distribution. The detected bias for Decubitus
The project team conducted extensive empirical ulcer is high, indicating that the measure is
analyses on the PSIs. Decubitus ulcer generally biased based on the characteristics observed. (It
performs well on several different dimensions, is possible that characteristics that are not
including reliability, bias, relatedness of observed using administrative data may be
indicators, and persistence over time. related to the patients risk of experiencing an
adverse event.) Risk adjustment is important for
Reliability. The signal ratiomeasured by the this indicator.
proportion of the total variation across hospitals
that is truly related to systematic differences Source
(signal) in hospital performance rather than
random variation (noise)is high, relative to This indicator was originally proposed by Iezzoni
other indicators, at 85.6%, suggesting that et al.39 as part of the Complications Screening
Program (CSP 6, cellulitis or decubitus ulcer).
35
Keeler E, Kahn K, Bentow S. Assessing quality of Needleman and Buerhaus identified decubitus
care for hospitalized Medicare patients with hip ulcer as an outcome potentially sensitive to
fracture using coded diagnoses from the Medicare nursing40 The American Nurses Association, its
Provider Analysis and Review file. Springfield, VA: State associations, and the California Nursing
NTIS; 1991. Outcomes Coalition have identified the total
36
prevalence of inpatients with Stage I, II, III, or IV
Berlowitz D, Brand H, Perkins C. Geriatric pressure ulcers as a nursing-sensitive quality
syndromes as outcome measures of hospital care: indicator for acute care settings.41
Can administrative data be used? JAGS 1999;47:692-
696.
39
Iezzoni LI, Daley J, Heeren T, Foley SM, Risher
37 ES, Duncan C, et al. Identifying complications of care
Needleman J, Buerhaus PI, Mattke S, Stewart M,
Zelevinsky K. Nurse Staffing and Patient Outcomes in using administrative data. Med Care 1994;32(7):700-
Hospitals. Boston, MA: Health Resources Services 15.
Administration; 2001 February 28. Report No.: 230-
40
88-0021. Needleman et al. 2001.

38 41
Lichtig LK, Knauf RA, Hilholland DK. Some impacts Nursing-Sensitive Quality Indicators for Acute Care
of nursing on acute care hospital outcomes. J Nurs Settings and ANAs Safety & Quality Initiative. In:
Adm 1999;29(2):25-33. American Nurses Association; 1999.
Version 2.1 28 Revision 1 (May 28, 2003)
Failure to Rescue

Definition Deaths per 1,000 patients having developed specified complications of care
during hospitalization.
Numerator Discharges with a disposition of deceased per 1,000 population at risk.
Denominator Discharges with potential complications of care listed in failure to rescue
definition (i.e., pneumonia, DVT/PE, sepsis, acute renal failure,
shock/cardiac arrest, or GI hemorrhage/acute ulcer). Exclusion criteria
specific to each diagnosis.
Exclude patients age 75 years and older.
Exclude neonatal patients in MDC 15.
Exclude patients transferred to an acute care facility.
Exclude patients transferred from an acute care facility.
Exclude patients admitted from a long-term care facility.
Type of Indicator Hospital level
Empirical Performance Rate: 148.4 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary from these complications. As a result, this

indicator definition was modified to exclude
This indicator is intended to identify patients who those patients age 75 years and older. In
die following the development of a complication. addition, panelists suggested the exclusion of
The underlying assumption is that good patients admitted from long-term care facilities.
hospitals identify these complications quickly
and treat them aggressively. Panelists noted that several adverse incentives
may be introduced by implementing this
Failure to rescue may be fundamentally different indicator. In particular, since some type of
than other indicators reviewed in this report, as it adjustment may be desirable, this indicator may
may reflect different aspects of quality of care encourage the upcoding of complications and
(effectiveness in rescuing a patient from a comorbidities to inflate the denominator or
complication versus preventing a complication). manipulate risk adjustment. Others noted that
This indicator includes pediatric patients. It is this indicator could encourage irresponsible
important to note that children beyond the resource use and allocation, although this is
neonatal period inherently recover better from likely to be a controversial idea. Finally,
physiological stress and thus may have a higher panelists emphasized that this indicator should
rescue rate. be used internally by hospitals, as it is not
validated for public reporting.
Panel Review
Literature Review
Panelists expressed concern regarding patients
with do not resuscitate (DNR) status. In cases Construct validity. Silber and colleagues have
where this DNR status is not a direct result of published a series of studies establishing the
poor quality of care, it would be contrary to construct validity of failure to rescue rates
patient desire and poor quality of care to rescue through their associations with hospital
a patient. In addition, very old patientsor characteristics and other measures of hospital
patients with advanced cancer or HIVmay not performance. Among patients admitted for
desire or may be particularly difficult to rescue cholecystectomy and transurethral

Version 2.1 29 Revision 1 (May 28, 2003)

prostatectomy, failure to rescue was random variation (noise)is moderately high,
independent of severity of illness at admission, relative to other indicators, at 66.6%, suggesting
but was significantly associated with the that observed differences in risk-adjusted rates
presence of surgical house staff and a lower may reflect true differences across hospitals.
percentage of board-certified
anesthesiologists.42 The adverse occurrence The signal standard deviation for this indicator is
rate was independent of this hospital also high, relative to other indicators, at 0.04617,
characteristic. In a larger sample of patients who indicating that the systematic differences (signal)
underwent general surgical procedures, lower among hospitals is high and more likely
failure to rescue rates were found at hospitals associated with hospital characteristics. The
with high ratios of registered nurses to beds.43 signal share is lower than many indicators, at
Failure rates were strongly associated with risk- 0.01450. The signal share is a measure of the
adjusted mortality rates, as expected, but not share of total variation (hospital and patient)
with complication rates.44 accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
More recently, Needleman and Buerhaus the rate and the more important other potential
confirmed that higher registered nurse staffing factors (e.g., patient characteristics).
(RN hours/adjusted patient day) and better
nursing skill mix (RN hours/licensed nurse Minimum bias. The project team assessed the
hours) were consistently associated with lower effect of age, gender, DRG, and comorbidity risk
failure to rescue rates, even using administrative adjustment on the relative ranking of hospitals
data to define complications.45 compared to no risk adjustment. They
measured (1) the impact of adjustment on the
Empirical Analysis assessment of relative hospital performance, (2)
the relative importance of the adjustment, (3) the
The project team conducted extensive empirical impact on hospitals with the highest and lowest
analyses on the PSIs. Failure to rescue rates, and (4) the impact throughout the
generally performs well on several different distribution. The detected bias for Failure to
dimensions, including reliability, bias, rescue is high, indicating that the measures are
relatedness of indicators, and persistence over biased based on the characteristics observed. (It
time. is possible that characteristics that are not
observed using administrative data may be
Reliability. The signal ratiomeasured by the related to the patients risk of experiencing an
proportion of the total variation across hospitals adverse event.) Risk adjustment is important for
that is truly related to systematic differences this indicator.
(signal) in hospital performance rather than
Source
42
Silber JH, Williams SV, Krakauer H, Schwartz JS. This indicator was originally proposed by Silber
Hospital and patient characteristics associated with et al. as a more powerful tool than the risk-
death after surgery. A study of adverse occurrence
adjusted mortality rate to detect true differences
and failure to rescue. Med Care 1992;30(7):615-29.
in patient outcomes across hospitals.46 The
43
Silber J, Rosenbaum P, Ross R. Comparing the underlying premise was that better hospitals are
contributions of groups of predictors: Which outcomes distinguished not by having fewer adverse
vary with hospital rather than patient characteristics? occurrences but by more successfully averting
J Am Stat Assoc 1995;90:7-18. death among (i.e., rescuing) patients who
experience such complications. More recently,
44
Silber JH, Rosenbaum PR, Williams SV, Ross RN, Needleman and Buerhaus adapted Failure to
Schwartz JS. The relationship between choice of rescue to administrative data sets, hypothesizing
outcome measure and hospital rank in general that this outcome might be sensitive to nurse
surgical procedures: Implications for quality staffing.47
assessment. Int J Qual Health Care 1997;9(3):193-
200.
45
Needleman J, Buerhaus PI, Mattke S, Stewart M,
Zelevinsky K. Nurse Staffing and Patient Outcomes in 46
Hospitals. Boston MA: Health Resources and Silber et al. 1992.
Services Administration; 2001 February 28. Report
47
No.:230-99-0021. Needleman et al. 2001.

Version 2.1 30 Revision 1 (May 28, 2003)

Foreign Body Left During Procedure
Hospital Level Definition
Definition Discharges with foreign body accidentally left in during procedure per 1,000
discharges.
Numerator Discharges with ICD-9-CM codes for foreign body left in during procedure in
any secondary diagnosis field per 1,000 surgical discharges.
Denominator All medical and surgical discharges defined by specific DRGs.
Type of Indicator Hospital level
Empirical Performance Rate: 0.09 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment Age, sex, DRG, comorbidity categories

Foreign Body Left During Procedure

Area Level Definition
Definition Discharges with foreign body accidentally left in during procedure per
100,000 population.
Numerator Discharges with ICD-9-CM codes for foreign body left in during procedure in
any diagnosis field (principal or secondary) of medical and surgical
discharges defined by specific DRGs.
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 1.05 per 100,000 population
Risk Adjustment No risk adjustment
Panelists also noted that the population at risk
Summary included both medical and surgical patients, but
not all of these patients are at risk. The panelists
This indicator is intended to flag cases of a felt that limiting the population at risk to surgical
foreign body accidentally left in a patient during patients would decrease the sensitivity of this
a procedure. This indicator is defined on both a indicator substantially. Since not all patients in
hospital level (by restricting cases to those the denominator are actually at risk, some
flagged by a secondary diagnosis or procedure hospitals may appear to have a lower rate if they
code) and an area level (by including all cases). have fewer medical patients who have
undergone invasive procedures.
Panel Review
Literature Review
Panelists believed that this indicator was useful
in identifying cases of a foreign body left in The literature review focused on the validity of
during a procedure. However, they suggested complication indicators based on ICD-9-CM
that each case identified be examined carefully diagnosis or procedure codes. Results of the
by the hospital, because this indicator was likely literature review indicate no published evidence
to yield few cases and some automated systems for the sensitivity or predictive value of this
report this complication when a foreign body is indicator based on detailed chart review or
left in intentionally. prospective data collection. Sensitivity is the
proportion of the patients who suffered an

Version 2.1 31 Revision 1 (May 28, 2003)

adverse event for whom that event was coded
on a discharge abstract or Medicare claim.
Predictive value is the proportion of patients with
a coded adverse event who were confirmed as
having suffered that event.

The project team found no published evidence

for this indicator that supports the following
constructs: (1) that hospitals that provide better
processes of care experience fewer adverse
events; (2) that hospitals that provide better
overall care experience fewer adverse events;
and (3) that hospitals that offer more nursing
hours per patient day, better nursing skill mix,
better physician skill mix, or more experienced
physicians have fewer adverse events.

Empirical Analysis

The project team conducted extensive empirical

analyses on the PSIs. Foreign body left during
procedure generally performs well on several
different dimensions, including reliability, bias,
relatedness of indicators, and persistence over
time. Due to the rarity of this diagnosis, reliability
and bias were not assessed.

Source

This indicator was originally proposed by Iezzoni

et al. as part of the Complications Screening
Program (CSP sentinel events).48 It was also
included as one component of a broader
indicator (adverse events and iatrogenic
complications) in AHRQs original HCUP
Quality Indicators.49 It was proposed by Miller et
al. in the Patient Safety Indicator Algorithms
and Groupings.50 Based on expert consensus
panels, McKesson Health Solutions included this
indicator in its CareEnhance Resource
Management Systems, Quality Profiler
Complications Measures Module.

48
Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-
15.
49
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Harris DR. Quality indicators using hospital discharge
data: state and national applications. Jt Comm J Qual
Improv 1998;24(2):88-105.
50
Miller M, Elixhauser A, Zhan C, Meyer G. Patient
safety indicators: Using administrative data to identify
potential patient safety concerns. Health Services
Research 2001;36(6 Part II):110-132.
Version 2.1 32 Revision 1 (May 28, 2003)
Iatrogenic Pneumothorax
Hospital Level Definition
Definition Cases of iatrogenic pneumothorax per 1,000 discharges.
Numerator Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field
per 1,000 discharges.
Denominator All discharges.
Exclude patients with any diagnosis of trauma.
Exclude patients with any code indicating thoracic surgery or lung or pleural
biopsy or assigned to cardiac surgery DRGs.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 0.83 per 1,000 population at risk
Bias: Some bias demonstrated
Risk Adjustment Age, sex, DRG, comorbidity categories

Iatrogenic Pneumothorax
Area Level Definition
Definition Cases of iatrogenic pneumothorax per 100,000 population.
Numerator Discharges with ICD-9-CM code of 512.1 in any diagnosis field (principal or
secondary).
Exclude patients with any diagnosis of trauma.
Exclude patients with any code indicating thoracic surgery or lung or pleural
biopsy or assigned to cardiac surgery DRGs.
Exclude obstetrical patients in MDC 14.
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 8.15 per 100,000 population
Risk Adjustment No risk adjustment

Summary susceptible to non-preventable iatrogenic

pneumothorax or may be miscoded for traumatic
This indicator is intended to flag cases of pneumothorax. The smaller anatomy of
pneumothorax caused by medical care. This children, especially neonates, may increase the
indicator is defined on both a hospital level (by technical complexity of these procedures in this
including cases of iatrogenic pneumothorax population (however, these procedures are less
occurring as a secondary diagnosis during likely to be performed in unmonitored settings).
hospitalization) and on an area level (by
including all cases of iatrogenic pneumothorax). Panel Review

Iatrogenic pneumothorax excludes all trauma Panelists rated the overall usefulness of this
patients because these patients may be more indicator favorably. The denominator of the

Version 2.1 33 Revision 1 (May 28, 2003)

definition that the panelists rated was limited to The project team conducted extensive empirical
patients receiving a central line, Swan-Ganz analyses on the PSIs. Iatrogenic pneumothorax
catheter, or thorocentesis. However, exploratory generally performs well on several different
empirical analyses found that this definition dimensions, including reliability, bias,
could not be operationalized using relatedness of indicators, and persistence over
administrative data, as these procedures time.
appeared to be under-reported. Although the
panelists noted that this complication, given the Reliability. The signal ratiomeasured by the
definition rated, reflected medical error, the proportion of the total variation across hospitals
actual final definition of this indicator includes that is truly related to systematic differences
cases that may be less reflective of medical (signal) in hospital performance rather than
error. Specifically, this indicator includes patients random variation (noise)is moderately high,
in whom a pneumothorax resulted from relative to other indicators, at 79.9%, suggesting
barotrauma, including patients with acute that observed differences in risk-adjusted rates
respiratory distress syndrome. may reflect true differences across hospitals.

Panelists expressed concern that some The signal standard deviation for this indicator is
approaches of placing a central line (e.g., lower than many indicators, at 0.00143,
subclavian) may be more likely to result in indicating that the systematic differences (signal)
pneumothorax than other approaches (e.g., among hospitals is low and less likely
internal jugular). However, other associated with hospital characteristics. The
complicationssuch as complications of the signal share is lower than many indicators, at
carotid arterywould be more common with 0.00183. The signal share is a measure of the
internal jugular approaches. Thus, if providers share of total variation (hospital and patient)
simply change approach, they may have a accounted for by hospitals. The lower the share,
decrease in pneumothorax but an increase in the less important the hospital in accounting for
other unmeasured complications. the rate and the more important other potential
factors (e.g., patient characteristics).
Literature Review
Minimum bias. The project team assessed the
The literature review focused on the validity of effect of age, gender, DRG, and comorbidity risk
complication indicators based on ICD-9-CM adjustment on the relative ranking of hospitals
diagnosis or procedure codes. Results of the compared to no risk adjustment. They
literature review indicate no published evidence measured (1) the impact of adjustment on the
for the sensitivity or predictive value of this assessment of relative hospital performance, (2)
indicator based on detailed chart review or the relative importance of the adjustment, (3) the
prospective data collection. Sensitivity is the impact on hospitals with the highest and lowest
proportion of the patients who suffered an rates, and (4) the impact throughout the
adverse event for whom that event was coded distribution. The detected bias for Iatrogenic
on a discharge abstract or Medicare claim. pneumothorax is moderate, indicating that the
Predictive value is the proportion of patients with measures may or may not be substantially
a coded adverse event who were confirmed as biased based on the characteristics observed.
having suffered that event.
Source
The project team found no published evidence
for this indicator that supports the following This diagnosis code was proposed by Miller et
constructs: (1) that hospitals that provide better al. as one component of a broader indicator
processes of care experience fewer adverse (iatrogenic conditions) in the Patient Safety
events; (2) that hospitals that provide better Indicator Algorithms and Groupings.51 It was
overall care experience fewer adverse events; also included as one component of a broader
and (3) that hospitals that offer more nursing indicator (adverse events and iatrogenic
hours per patient day, better nursing skill mix, complications) in AHRQs Version 1.3 HCUP
better physician skill mix, or more experienced Quality Indicators.
physicians have fewer adverse events.
51
Miller M, Elixhauser A, Zhan C, Meyer G. Patient
Empirical Analysis safety indicators: Using administrative data to identify
potential patient safety concerns. Health Services
Research 2001;36(6 Part II):110-132.
Version 2.1 34 Revision 1 (May 28, 2003)
Selected Infections Due to Medical Care
Hospital Level Definition
Definition Cases of ICD-9-CM codes 9993 or 99662 per 1,000 discharges.
Numerator Discharges with ICD-9-CM code of 9993 or 99662 in any secondary
diagnosis field per 1,000 discharges.
Denominator All medical and surgical discharges defined by specific DRGs.
Exclude patients with any diagnosis code for immunocompromised state or
cancer.
Type of Indicator Hospital level
Empirical Performance Rate: 1.99 per 1,000 population at risk
Bias: Some bias demonstrated
Risk Adjustment Age, sex, DRG, comorbidity categories

Selected Infections Due to Medical Care

Area Level Definition
Definition Cases of ICD-9-CM codes 9993 or 99662 per 100,000 population.
Numerator Discharges with ICD-9-CM code of 9993 or 99662 in any diagnosis field
(principal or secondary) of medical and surgical discharges defined by
specific DRGs.
Exclude patients with any diagnosis code for immunocompromised state or
cancer.
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 34.18 per 100,000 population
Risk Adjustment No risk adjustment

Summary infections.

This indicator is intended to flag cases of Panel Review

infection due to medical care, primarily those
related to intravenous (IV) lines and catheters. Panelists expressed particular interest in
This indicator is defined both on a hospital level tracking IV and catheter-related infections,
(by including cases based on secondary despite the potential for bias due to charting or
diagnosis associated with the same under-reporting. For the most part, they felt that
hospitalization) and on an area level (by these complications were important to track. As
including all cases of such infection). Patients with other indicators tracking infections, concern
with potential immunocompromised states (e.g., regarding the potential overuse of prophylactic
AIDS, cancer, transplant) are excluded, as they antibiotics remains.
may be more susceptible to such infection.
Literature Review
This indicator includes children and neonates. It
should be noted that high-risk neonates are at The literature review focused on the validity of
particularly high risk for catheter-related complication indicators based on ICD-9-CM

Version 2.1 35 Revision 1 (May 28, 2003)

diagnosis or procedure codes. Results of the compared to no risk adjustment. They
literature review indicate no published evidence measured (1) the impact of adjustment on the
for the sensitivity or predictive value of this assessment of relative hospital performance, (2)
indicator based on detailed chart review or the relative importance of the adjustment, (3) the
prospective data collection. Sensitivity is the impact on hospitals with the highest and lowest
proportion of the patients who suffered an rates, and (4) the impact throughout the
adverse event for whom that event was coded distribution. The detected bias for Selected
on a discharge abstract or Medicare claim. infections due to medical care is moderate,
Predictive value is the proportion of patients with indicating that the measures may or may not be
a coded adverse event who were confirmed as substantially biased based on the characteristics
having suffered that event. observed. (It is possible that characteristics that
are not observed using administrative data may
The project team found no published evidence be related to the patients risk of experiencing an
for this indicator that supports the following adverse event.)
constructs: (1) that hospitals that provide better
processes of care experience fewer adverse Source
events; (2) that hospitals that provide better
overall care experience fewer adverse events; This indicator was originally proposed by Iezzoni
and (3) that hospitals that offer more nursing et al. as part of the Complications Screening
hours per patient day, better nursing skill mix, Program (CSP 11, miscellaneous
better physician skill mix, or more experienced complications).52 The University HealthSystem
physicians have fewer adverse events. Consortium adopted the CSP indicator for major
(#2933) and minor (#2961) surgery patients. A
Empirical Analysis much narrower definition, including only 9993
(other infection after infusion, injection,
The project team conducted extensive empirical transfusion, vaccination), was proposed by
analyses on the PSIs. Selected infections due Miller et al. in the Patient Safety Indicator
to medical care generally performs well on Algorithms and Groupings.53 The American
several different dimensions, including reliability, Nurses Association and its State associations
bias, relatedness of indicators, and persistence have identified the number of laboratory-
over time. confirmed bacteremic episodes associated with
central lines per critical care patient day as a
Reliability. The signal ratiomeasured by the nursing-sensitive quality indicator for acute care
proportion of the total variation across hospitals settings.54
that is truly related to systematic differences
(signal) in hospital performance rather than
random variation (noise)is moderately high,
relative to other indicators, at 70.8%, suggesting
that observed differences in risk-adjusted rates
may reflect true differences across hospitals.

The signal standard deviation for this indicator is

lower than many indicators, at 0.00134,
indicating that the systematic differences (signal)
among hospitals is low and less likely
associated with hospital characteristics. The
52
signal share is lower than many indicators, at Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
0.00095. The signal share is a measure of the ES, Duncan C, et al. Identifying complications of care
share of total variation (hospital and patient) using administrative data. Med Care 1994;32(7):700-
accounted for by hospitals. The lower the share, 15.
the less important the hospital in accounting for 53
Miller M, Elixhauser A, Zhan C, Meyer G. Patient
the rate and the more important other potential
safety indicators: Using administrative data to identify
factors (e.g., patient characteristics). potential patient safety concerns. Health Services
Research 2001;36(6 Part II):110-132.
Minimum bias. The project team assessed the
54
effect of age, gender, DRG, and comorbidity risk Nursing-Sensitive Quality Indicators for Acute Care
adjustment on the relative ranking of hospitals Settings and ANAs Safety and Quality Initiative. In:
American Nurses Association; 1999.
Version 2.1 36 Revision 1 (May 28, 2003)
Postoperative Hemorrhage or Hematoma

Definition Cases of hematoma or hemorrhage requiring a procedure per 1,000

surgical discharges.
Numerator Discharges with ICD-9-CM codes for postoperative hemorrhage or
postoperative hematoma in any secondary diagnosis field and code for
postoperative control of hemorrhage or drainage of hematoma
(respectively) in any secondary procedure code field per 1,000 discharges.
Procedure code for postoperative control of hemorrhage or hematoma must
occur on the same day or after the principal procedure.
Note: If day of procedure is not available in the input data file, the rate may
be slightly higher than if the information was available.
Denominator All surgical discharges defined by specific DRGs.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 1.61 per 1,000 population at risk

Bias: Not detected in empirical tests

Risk Adjustment Age, sex, DRG, comorbidity categories

Summary Literature Review

This indicator is intended to capture cases of Coding validity. The original CSP definition had
hemorrhage or hematoma following a surgical a relatively high confirmation rate among major
procedure. This indicator limits hemorrhage and surgical cases (83% by coders review, 57% by
hematoma codes to secondary procedure and physicians review, 52% by nurse-abstracted
diagnosis codes, respectively, to isolate those clinical documentation, and 76% if nurses also
hemorrhages that can truly be linked to a accepted physicians notes as adequate
surgical procedure. documentation).55 56 57 Hartz and Kuhn
estimated the validity of hemorrhage codes
Panel Review using a gold standard based on transfusion
requirement. 58 They identified only 26% of
Panelists noted that some patients may be at
55
higher risk for developing a postoperative Lawthers A, McCarthy E, Davis R, Peterson L,
hemorrhage or hematoma. Specifically, they Palmer R, Iezzoni L. Identification of in-hospital
were concerned about patients with complications from claims data: Is it valid? Med Care
coagulopathies and those on anticoagulants. 2000;38(8):785-795.
They suggested that where possible, this 56
indicator be stratified for patients with underlying McCarthy EP, Iezzoni LI, Davis RB, Palmer RH,
clotting differences. They also noted that Cahalane M, Hamel MB, et al. Does clinical evidence
support ICD-9-CM diagnosis coding of complications?
patients admitted for trauma may be at a higher Med Care 2000;38(8):868-876.
risk for developing postoperative hemorrhage or
may have a hemorrhage diagnosed that 57
Weingart SN, Iezzoni LI, Davis RB, Palmer RH,
occurred during the trauma. They also Cahalane M, Hamel MB, et al. Use of administrative
suggested that this indicator be stratified for data to find substandard care: Validation of the
trauma and non-trauma patients. Complications Screening Program. Med Care
2000;38(8):796-806.
58
Hartz AJ, Kuhn EM. Comparing hospitals that
perform coronary artery bypass surgery: The effect of
Version 2.1 37 Revision 1 (May 28, 2003)
episodes of bleeding (defined as requiring return among hospitals is low and less likely
to surgery or transfusion of at least six units of associated with hospital characteristics. The
blood products) by applying this indicator (9981) signal share is lower than many indicators, at
to Medicare patients who underwent coronary 0.00006. The signal share is a measure of the
artery bypass surgery; the predictive value was share of total variation (hospital and patient)
75%. accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
Construct Validity. Explicit process of care the rate and the more important other potential
failures in the CSP validation study were factors (e.g., patient characteristics).
relatively frequent among major surgical cases
with CSP 24, but not among medical cases Minimum bias. The project team assessed the
(66% and 13%, respectively), after excluding effect of age, gender, DRG, and comorbidity risk
patients who had hemorrhage or hematoma at adjustment on the relative ranking of hospitals
admission.59 Cases flagged on this indicator and compared to no risk adjustment. They
unflagged controls did not differ significantly on measured (1) the impact of adjustment on the
a composite of 17 generic process criteria. assessment of relative hospital performance, (2)
Similarly, cases flagged on this indicator and the relative importance of the adjustment, (3) the
unflagged controls did not differ significantly on impact on hospitals with the highest and lowest
a composite of four specific process criteria for rates, and (4) the impact throughout the
major surgical cases and two specific process distribution. The detected bias for Postoperative
criteria for medical cases in the earlier study of hemorrhage or hematoma is low, indicating that
elderly Medicare beneficiaries.60 the measures are likely not biased based on the
characteristics observed. (It is possible that
Empirical Analysis characteristics that are not observed using
administrative data may be related to the
The project team conducted extensive empirical patients risk of experiencing an adverse event.)
analyses on the PSIs. Postoperative
hemorrhage or hematoma generally performs Source
well on several different dimensions, including
reliability, bias, relatedness of indicators, and This indicator was originally proposed by Iezzoni
persistence over time. et al.61 as part of the Complications Screening
Program (CSP 24, post-procedural hemorrhage
Reliability. The signal ratiomeasured by the or hematoma), although their definition allowed
proportion of the total variation across hospitals either procedure or diagnosis codes. By
that is truly related to systematic differences contrast, the current definition requires a
(signal) in hospital performance rather than hemorrhage or hematoma diagnosis with an
random variation (noise)is lower than most associated procedure to either control the
indicators, at 8.6%, suggesting that observed hemorrhage or drain the hematoma. It was also
differences in risk-adjusted rates may not reflect included as one component of a broader
true differences across hospitals. indicator (adverse events and iatrogenic
complications) in AHRQs original HCUP
The signal standard deviation for this indicator is Quality Indicators.62
lower than most indicators, at 0.00039,
indicating that the systematic differences (signal)

outcome measures and data sources. Am J Public

Health 1994;84(10):1609-14.
59
Iezzoni LI, Davis RB, Palmer RH, Cahalane M,
61
Hamel MB, Mukamal K, et al. Does the complications Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
Screening Program flag case with process of care ES, Duncan C, et al. Identifying complications of care
problems? Using explicit criteria to judge processes. using administrative data. Med Care 1994;32(7):700-
Int J Qual Health Care 1999;11(2):107-18. 15.
60 62
Iezzoni L, Lawthers A, Petersen L, McCarthy E, Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Palmer R, Cahalane M, et al. Project to validate the Harris DR. Quality indicators using hospital discharge
Complications Screening Program: Health Care data: State and national applications. Jt Comm J Qual
Financing Administration; 1998 March 31. Report No: Improv 1998;24(2):88-105. Published erratum
HCFA Contract 500-94-0055. appears in Jt Comm J Qual Improv 1998;24(6):341.
Version 2.1 38 Revision 1 (May 28, 2003)
Postoperative Hip Fracture

Definition Cases of in-hospital hip fracture per 1,000 surgical discharges.

Numerator Discharges with ICD-9-CM code for fracture in any secondary diagnosis
field per 1,000 surgical discharges.
Denominator All surgical discharges defined by specific DRGs.
Exclude all patients with diseases and disorders of the musculoskeletal
system and connective tissue (MDC 8).
Exclude patients with principal diagnosis codes for seizure, syncope, stroke,
coma, cardiac arrest, anoxic brain injury, poisoning, delirium or other
psychoses, trauma.
Exclude patients with any diagnosis of metastatic cancer, lymphoid
malignancy, bone malignancy or self-inflicted injury.
Exclude obstetrical patients in MDC 14.
Exclude patients 17 years of age or younger.
Type of Indicator Hospital level
Empirical Performance Rate: 0.94 per 1,000 population at risk
Bias: Some bias demonstrated
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary they did not have a substantial number of cases

in the numerator.
This indicator is intended to capture cases of in-
hospital fracturespecifically, hip fractures. This Panelists noted that this indicator may be slightly
indicator limits diagnosis codes to secondary biased for hospitals that care for more of the
diagnosis codes to eliminate fractures that were elderly and frail, because they have weaker
present on admission. It further excludes bones and are more susceptible to falls.
patients in MDC 8 (musculoskeletal disorders)
and patients with indications for trauma or Panelists were interested in capturing all
cancer, or principal diagnoses of seizure, fractures occurring in-hospital, although it was
syncope, stroke, coma, cardiac arrest, or not possible to operationalize this suggestion.
poisoning, as these patients may have a fracture
present on admission. This indicator is limited to Literature Review
surgical cases since previous research
suggested that these codes in medical patients Coding validity. The original CSP definition had
often represent conditions present on admission an adequate confirmation rate among major
(see Literature Review). surgical cases in Medicare inpatient claims files
(57% by coders review, 71% by physicians
Panel Review review), but a very poor confirmation rate among
medical cases (11% by both coders and
Although this indicator was initially presented as physicians review).63 64 This problem was
"In-hospital hip fracture and fall," panelists
unanimously suggested that falls should be 63
Lawthers A, McCarthy E, Davis R, Peterson L,
eliminated from this indicator and that all in- Palmer R, Iezzoni L. Identification of in-hospital
hospital fractures should be included. The complications from claims data: Is it valid? Med Care
resulting indicator was termed "In-hospital 2000;38(8):785-795.
fracture possibly related to falls." Children were 64
excluded after empirical analysis revealed that Weingart SN, Iezzoni LI, Davis RB, Palmer RH,
Cahalane M, Hamel MB, et al. Use of administrative
Version 2.1 39 Revision 1 (May 28, 2003)
attributable to the fact that most hip fractures the rate and the more important other potential
among medical inpatients were actually factors (e.g., patient characteristics).
comorbid diagnoses present at admission rather
than complications of hospital care. Nurse Minimum bias. The project team assessed the
reviews were not performed. effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
Construct validity. Explicit process of care compared to no risk adjustment. They
failures in the CSP validation study were measured (1) the impact of adjustment on the
relatively frequent among cases with CSP 25 assessment of relative hospital performance, (2)
(76% of major surgery patients, 54% of medical the relative importance of the adjustment, (3) the
patients), after excluding patients who had hip impact on hospitals with the highest and lowest
fractures at admission, but unflagged controls rates, and (4) the impact throughout the
were not evaluated on the same criteria.65 distribution. The detected bias for Postoperative
Physician reviewers identified potential quality hip fracture is moderate, indicating that the
problems in 24% of major surgery patients and measures may or may not be substantially
5% of medical patients with CSP 25 (versus 2% biased based on the characteristics observed. (It
of unflagged controls for each risk group).66 is possible that characteristics that are not
observed using administrative data may be
Empirical Analysis related to the patients risk of experiencing an
adverse event.)
The project team conducted extensive empirical
analyses on the PSIs. Postoperative hip Source
fracture generally performs well on several
different dimensions, including reliability, bias, This indicator was originally proposed by Iezzoni
relatedness of indicators, and persistence over et al.67 as part of the Complications Screening
time. Program (CSP 25, in-hospital hip fracture or
fall). Their definition also includes any
Reliability. The signal ratiomeasured by the documented fall, based on external cause of
proportion of the total variation across hospitals injury codes. Needleman and Buerhaus
that is truly related to systematic differences considered in-hospital hip fracture as an
(signal) in hospital performance rather than Outcome Potentially Sensitive to Nursing, but
random variation (noise)is moderately high, discarded it because the event rate was too low
relative to other indicators, at 67.1%, suggesting to be useful.68 The American Nurses
that observed differences in risk-adjusted rates Association, its State associations, and the
may reflect true differences across hospitals. California Nursing Outcomes Coalition have
identified the number of patient falls leading to
The signal standard deviation for this indicator is injury per 1,000 patient days (based on clinical
lower than many indicators, at 0.00184, data collection) as a nursing-sensitive quality
indicating that the systematic differences (signal) indicator for acute care settings.69
among hospitals is low and less likely
associated with hospital characteristics. The
signal share is lower than many indicators, at
0.00403. The signal share is a measure of the
share of total variation (hospital and patient)
accounted for by hospitals. The lower the share,
67
the less important the hospital in accounting for Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-
data to find substandard care: Validation of the 15.
Complications Screening Program. Med Care
68
2000;38(8):796-806. Needleman J, Buerhaus PI, Mattke S, Stewart M,
65
Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Zelevinsky K. Nurse Staffing and Patient Outcomes in
Hamel MB, Mukamal K, et al. Does the Complications Hospitals. Boston, MA: Health Resources Services
Screening Program flag cases with process of care Administration; 2001 February 28. Report No.: 230-
problems: Using explicit criteria to judge processes. 99-0021.
Int J Qual Health Care 1999;11(2):107-18.
69
Nursing-Sensitive Quality Indicators for Acute Care
66
Weingart et al. 2000. Settings and ANAs Safety & Quality Initiative. In:
American Nurses Association; 1999.
Version 2.1 40 Revision 1 (May 28, 2003)
Postoperative Physiologic and Metabolic Derangement

Definition Cases of specified physiological or metabolic derangement per 1,000

elective surgical discharges.
Numerator Discharges with ICD-9-CM codes for physiologic and metabolic
derangements in any secondary diagnosis field per 1,000 elective surgical
discharges.
Discharges with acute renal failure (subgroup of physiologic and metabolic
derangements) must be accompanied by a procedure code for dialysis
(3995, 5498).
Denominator All elective surgical discharges defined by admit type.
Exclude patients with both a diagnosis code of ketoacidosis,
hyperosmolarity, or other coma (subgroups of physiologic and metabolic
derangements coding) and a principal diagnosis of diabetes.
Exclude patients with both a secondary diagnosis code for acute renal
failure (subgroup of physiologic and metabolic derangements coding) and a
principal diagnosis of acute myocardial infarction, cardiac arrhythmia,
cardiac arrest, shock, hemorrhage, or gastrointestinal hemorrhage.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 0.83 per 1,000 population at risk
Bias: Some bias demonstrated
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary Panelists noted that coding of relatively transient

metabolic and physiologic complications may be
This indicator is intended to flag cases of lacking, such as in cases of diabetic
postoperative metabolic or physiologic ketoacidosis. Conversely, some physicians may
complications. The population at risk is limited to capture non-clinically significant events in this
elective surgical patients, because patients indicator.
undergoing non-elective surgery may develop
less preventable derangements. In addition, This indicator includes pediatric patients, which
each diagnosis has specific exclusions, was not specifically discussed by the panel. The
designed to reduce the number of flagged cases incidence of these complications is a function of
in which the diagnosis was present on the underlying prevalence of diabetes and renal
admission or was more likely to be non- impairment, which are less common among
preventable. children than among adults.

Panel Review Literature Review

Panelists expressed concern that acute renal Coding validity. No evidence on validity is
failure suffers from the problem of varied available from CSP studies. Geraci et al.70
definition: what one doctor may call acute renal
failure, another may not. To ensure that the only 70
renal failure cases that are picked up are those Geraci JM, Ashton CM, Kuykendall DH, Johnson
that are clinically severe, the panel suggested ML, Wu L. International Classification of Diseases, 9th
Revision, Clinical Modification codes in discharge
that acute renal failure be included only when it
abstracts are poor measures of complication
is paired with a procedure code for dialysis. occurrence in medical inpatients. Med Care
1997;35(6):589-602.
Version 2.1 41 Revision 1 (May 28, 2003)
confirmed only 5 of 15 episodes of acute renal indicators, at 20.9%, suggesting that observed
failure and 12 of 34 episodes of hypoglycemia differences in risk-adjusted rates may not reflect
reported on discharge abstracts of VA patients true differences across hospitals.
hospitalized for CHF, COPD, or diabetes.
Romano reported no false positives in episodes The signal standard deviation for this indicator is
of acute renal failure or hypoglycemia using lower than many indicators, at 0.00054,
discharge abstracts of diskectomy patients.71 indicating that the systematic differences (signal)
ICD-9-CM diagnoses (585 or 7885) had a among hospitals is low and less likely
sensitivity of 8% and a predictive value of 4% in associated with hospital characteristics. The
comparison with the VAs National Surgical signal share is lower than many indicators, at
Quality Improvement Program database, which 0.00033. The signal share is a measure of the
defines renal failure as requiring dialysis within share of total variation (hospital and patient)
30 days after surgery.72 accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
Construct Validity. After adjusting for patient the rate and the more important other potential
demographic, geographic, and hospital factors (e.g., patient characteristics).
characteristics, Hannan et al. reported that
cases with a secondary diagnosis of fluid and Minimum bias. The project team assessed the
electrolyte disorders were no more likely to have effect of age, gender, DRG, and comorbidity risk
received care that departed from professionally adjustment on the relative ranking of hospitals
recognized standards than cases without that compared to no risk adjustment. They
code (2.2% versus 1.7%, OR=1.13).73 However, measured (1) the impact of adjustment on the
these ICD-9-CM codes were omitted from the assessment of relative hospital performance, (2)
accepted AHRQ PSIs. the relative importance of the adjustment, (3) the
impact on hospitals with the highest and lowest
Empirical Evidence rates, and (4) the impact throughout the
distribution. The detected bias for Postoperative
The project team conducted extensive empirical physiologic and metabolic derangements is
analyses on the PSIs. Postoperative physiologic moderate, indicating that the measures may or
and metabolic derangements generally performs may not be substantially biased based on the
well on several different dimensions, including characteristics observed. (It is possible that
reliability, bias, relatedness of indicators, and characteristics that are not observed using
persistence over time. administrative data may or may not be related to
the patients risk of experiencing an adverse
Reliability. The signal ratiomeasured by the event.)
proportion of the total variation across hospitals
that is truly related to systematic differences Source
(signal) in hospital performance rather than
random variation (noise)is lower than many This indicator was originally proposed by Iezzoni
et al.74 as part of the CSP (CSP 20,
postoperative physiologic and metabolic
71
Romano P. Can administrative data be used to
derangements). The University HealthSystem
ascertain clinically significant postoperative Consortium adopted the CSP indicator for major
complications. American Journal of Medical Quality surgery patients (#2945).
Press.
72
Best W, Khuri S, Phelan M, Hur K, Henderson W,
Demakis J, et al. Identifying patient preoperative risk
factors and postoperative adverse events in
administrative databases: Results from the
Department of Veterans Affairs National Surgical
Quality Improvement Program. J Am Coll Surg
2002;194(3):257-266.
73
Hannan EL, Bernard HR, ODonnell JF, Kilburn H,
74
Jr. A methodology for targeting hospital cases for Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
quality of care record reviews. Am J Public Health ES, Duncan C, et al. Identifying complications of care
1989;79(4):430-6. using administrative data. Med Care 1994;32(7):700-
15.
Version 2.1 42 Revision 1 (May 28, 2003)
Postoperative Pulmonary Embolism or Deep Vein Thrombosis

Definition Cases of deep vein thrombosis (DVT) or pulmonary embolism (PE) per
1,000 surgical discharges.
Numerator Discharges with ICD-9-CM codes for deep vein thrombosis or pulmonary
embolism in any secondary diagnosis field per 1,000 surgical discharges.
Denominator All surgical discharges defined by specific DRGs.
Exclude patients with a principal diagnosis of deep vein thrombosis.
Exclude obstetrical patients in MDC 14.
Exclude patients with secondary procedure code 38.7 when this procedure
occurs on the day of or previous to the day of the principal procedure.
Note: If day of procedure is not available in the input data file, the rate may
be slightly lower than if the information was available.
Type of Indicator Hospital level
Empirical Performance Rate: 9.59 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary
Literature Review
This indicator is intended to capture cases of
postoperative venous thromboses and Coding validity. Geraci et al. confirmed only 1 of
embolismspecifically, pulmonary embolism 6 episodes of DVT or PE reported on discharge
and deep venous thrombosis. This indicator abstracts of VA patients for CHF, COPD, or
limits vascular complications codes to secondary diabetes; the sensitivity was 100%.75 Among
diagnosis codes to eliminate complications that Medicare hip fracture patients, by contrast,
were present on admission. It further excludes Keeler et al. confirmed 88% of reported PE
patients who have principal diagnosis of DVT, as cases, and failed to ascertain just 6 cases (65%
these patients are likely to have had PE/DVT sensitivity) using ICD-9-CM codes.76 For DVT,
present on admission. they found just 1 of 6 cases using ICD-9-CM
codes (but no false positive codes). Other
Panel Review studies have demonstrated that ICD-9-CM
codes for DVT and PE have high predictive
Panelists rated the overall usefulness of this value when listed as the principal diagnosis for
indicator relatively highly as compared to other readmissions after major orthopedic surgery
indicators. They noted that preventative (100%) or after inferior vena cava filter
techniques should decrease the rate of this
indicator. This indicator includes pediatric
patients. In the absence of specific thrombophilic 75
Geraci JM, Ashton CM, Kuykendall DH, Johnson
disorders, postoperative thromboembolic ML, Wu L. In-hospital complications among survivors
complications in children are most likely to be of admission for congestive heart failure, chronic
secondary to venous catheters rather than obstructive pulmonary disease, or diabetes mellitus. J
venous stasis in the lower extremities. Gen Intern Med 1995;10(6):307-14.
76
Because the risk for DVT/PE varies greatly Keeler E, Kahn K, Bentow S. Assessing quality of
according to the type of procedure performed, care for hospitalized Medicare patients with hip
fracture using coded diagnoses from the Medicare
panelists suggested that this indicator be
Provider Analysis and Review File. Springfield, VA:
adjusted or stratified according to surgical NTIS;1991.
procedure types.

Version 2.1 43 Revision 1 (May 28, 2003)

placement (98%).77 However, these findings do lower than many indicators, at 0.00633,
not directly address the validity of DVT/PE as a indicating that the systematic differences (signal)
secondary diagnosis among patients treated by among hospitals is low and less likely
anticoagulation. associated with hospital characteristics. The
signal share is lower than many indicators, at
Construct validity. Explicit process of care 0.00511. The signal share is a measure of the
failures in the CSP validation study were share of total variation (hospital and patient)
relatively frequent among both major surgical accounted for by hospitals. The lower the share,
and medical cases with CSP 22 (72% and 69%, the less important the hospital in accounting for
respectively), after disqualifying cases in which the rate and the more important other potential
DVT/PE was actually present at admission.78 factors (e.g., patient characteristics).
Needleman and Buerhaus found that nurse
staffing was independent of the occurrence of Minimum bias. The project team assessed the
DVT/PE among both major surgical or medical effect of age, gender, DRG, and comorbidity risk
patients.79 However, Kovner and Gergen adjustment on the relative ranking of hospitals
reported that having more registered nurse compared to no risk adjustment. They
hours and non-RN hours was associated with a measured (1) the impact of adjustment on the
lower rate of DVT/PE after major surgery.80 assessment of relative hospital performance, (2)
the relative importance of the adjustment, (3) the
Empirical Analysis impact on hospitals with the highest and lowest
rates, and (4) the impact throughout the
The project team conducted extensive empirical distribution. The detected bias for Postoperative
analyses on the PSIs. Postoperative PE or DVT PE or DVT is high, indicating that the measures
generally performs well on several different likely are biased based on the characteristics
dimensions, including reliability, bias, observed. (It is possible that characteristics that
relatedness of indicators, and persistence over are not observed using administrative data may
time. be related to the patients risk of experiencing an
adverse event.) Risk adjustment is important for
Reliability. The signal ratiomeasured by the this indicator.
proportion of the total variation across hospitals
that is truly related to systematic differences Source
(signal) in hospital performance rather than
random variation (noise)is moderately high, This indicator was originally proposed by Iezzoni
relative to other indicators, at 72.6%, suggesting et al. as part of the Complications Screening
that observed differences in risk-adjusted rates Program (CSP 22, venous thrombosis and
likely reflect true differences across hospitals. pulmonary embolism)81 and was one of AHRQs
original HCUP Quality Indicators for major
The signal standard deviation for this indicator is surgery and invasive vascular procedure
patients.82 A code that maps to this indicator in
77 the final AHRQ PSI was proposed by Miller et al.
White RH, Romano P, Zhou H, Rodrigo J, Barger
as one component of a broader indicator
W. Incidence and time course of thromboembolic
outcomes following total hip or knee arthroplasty. (iatrogenic conditions).83
Arch Intern Med 1998;158(14):1525-31.
78 81
Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
Hamel MB, Mukamal K, et al. Does the Complications ES, Duncan C, et al. Identifying complications of care
Screening Program flag cases with process of care using administrative data. Med Care 1994;32(7):700-
problems? Using explicit criteria to judge processes. 15.
Int J Qual Health Care 1999;11(2):107-18.
82
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
79
Needleman J, Buerhaus PI, Mattke S, Stewart M, Harris DR. Quality indicators using hospital discharge
Zelevinsky K. Nurse Staffing and Patient Outcomes in data: State and national applications. Jt Comm J Qual
Hospitals. Boston, MA: Health Resources Services Improv 1998;24(2):88-195. Published erratum
Administration; 2001 February 28. Report No.:230-99- appears in Jt Comm J Qual Improv 1998;24(6):341.
0021.
83
Miller M, Elixhauser A, Zhan C, Meyer G. Patient
80
Kovner C, Gergen PH. Nurse staffing levels and safety indicators: Using administrative data to identify
adverse events following surgery in U.S. hospitals. potential patient safety concerns. Health Services
Image J Nurs Sch 1998;30(4):315-21. Research 2001;36(6 Part II):110-132.
Version 2.1 44 Revision 1 (May 28, 2003)
Postoperative Respiratory Failure

Definition Cases of acute respiratory failure per 1,000 elective surgical discharges.
Numerator Discharges with ICD-9-CM codes for acute respiratory failure (518.81) in
any secondary diagnosis field per 1,000 discharges (After 1999, include
51884).
Denominator All elective surgical discharges defined by admit type.
Exclude patients with respiratory or circulatory diseases (MDC 4 and MDC
5).
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 3.64 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary reviews were not performed.

This indicator is intended to flag cases of Geraci et al. confirmed 1 of 2 episodes of

postoperative respiratory failure. This indicator respiratory failure reported on discharge
limits the code for respiratory failure to abstracts of VA patients hospitalized for CHF or
secondary diagnosis codes to eliminate diabetes; the sensitivity for respiratory
respiratory failure that was present on decompensation requiring mechanical
admission. It further excludes patients who ventilation was 25%.86
have major respiratory or circulatory disorders
and limits the population at risk to elective Construct Validity. Explicit process of care
surgery patients. failures in the CSP validation study were slightly
but not significantly more frequent among major
Panel Review surgical cases with CSP 3 than among
unflagged controls (52% versus 46%).87 Indeed,
Panelists rated the overall usefulness of this cases flagged on this indicator were significantly
indicator as relatively favorable. They felt that less likely than unflagged controls (24% versus
only acute respiratory failure should be retained 64%) to have at least one of four specific
in this indicator and noted that this clinically process-of-care problems in the earlier study of
significant event is at least partially preventable.

Literature Review
data to find substandard care: Validation of the
Complications Screening Program. Med Care
Coding Validity. CSP 3 had a relatively high
2000;38(8):796-806.
confirmation rate among major surgical cases in
the FY1994 Medicare inpatient claims files from 86
Geraci JM, Ashton CM, Kuykendall DH, Johnson
California and Connecticut (72% by coders ML, Wu L. In-hospital complications among survivors
review, 75% by physicians review).84 85 Nurse of admission for congestive heart failure, chronic
obstructive pulmonary disease, or diabetes mellitus. J
Gen Intern Med 1995;10(6):307-14.
84
Lawthers a, McCarthy E, Davis R, Peterson L,
87
Palmer R, Iezzoni L. Identification of in-hospital Iezzoni LI, Davis RB, Palmer RH, Cahalane M,
complications from claims data: is it valid? Med Care Hamel MB, Mukamal K, et al. Does the Complications
2000;38(8):785-795. Screening Program flag cases with process of care
problems? Using explicit criteria to judge processes.
85
Weingart SN, Iezzoni LI, Davis RB, Palmer RH, Int J Qual Health Care 1999;11(2):107-18.
Cahalane M, Hamel MB, et al. Use of administrative
Version 2.1 45 Revision 1 (May 28, 2003)
elderly Medicare beneficiaries.88 effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
Needleman and Buerhaus found that nurse compared to no risk adjustment. They
staffing was independent of the occurrence of measured (1) the impact of adjustment on the
pulmonary failure among major surgery assessment of relative hospital performance, (2)
patients.89 However, Kovner and Gergen the relative importance of the adjustment, (3) the
reported that having more registered nurse impact on hospitals with the highest and lowest
hours per adjusted patient day was associated rates, and (4) the impact throughout the
with a lower rate of pulmonary compromise distribution. The detected bias for Postoperative
after major surgery.90 respiratory failure is high, indicating that the
measures likely are biased based on the
Empirical Analysis characteristics observed. (It is possible that
characteristics that are not observed using
The project team conducted extensive empirical administrative data may be related to the
analyses on the PSIs. Postoperative respiratory patients risk of experiencing an adverse event.)
failure generally performs well on several Risk adjustment is important for this indicator.
different dimensions, including reliability, bias,
relatedness of indicators, and persistence over Source
time.
This indicator was originally proposed by Iezzoni
Reliability. The signal ratiomeasured by the et al. as part of the CSP (CSP 3, postoperative
proportion of the total variation across hospitals pulmonary compromise).91 Their definition also
that is truly related to systematic differences includes pulmonary congestion, other (or
(signal) in hospital performance rather than postoperative) pulmonary insufficiency, and
random variation (noise)is lower than many acute pulmonary edema, which were omitted
indicators, at 46.6%, suggesting that observed from this PSI. The University HealthSystem
differences in risk-adjusted rates may not reflect Consortium (#2927) and AHRQs original HCUP
true differences across hospitals. Quality Indicators adopted the CSP indicator for
major surgery patients.92 Needleman and
The signal standard deviation for this indicator is Buerhaus identified postoperative pulmonary
lower than many indicators, at 0.00230, failure as an Outcome Potentially Sensitive to
indicating that the systematic differences (signal) Nursing, using the original CSP definition.93
among hospitals is low and less likely
associated with hospital characteristics. The
signal share is lower than many indicators, at
0.00187. The signal share is a measure of the
share of total variation (hospital and patient)
accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
the rate and the more important other potential
factors (e.g., patient characteristics).

Minimum bias. The project team assessed the

88
Hawker GA, Coyte PC, Wright JG, Paul JE,
Bombardier C. Accuracy of administrative data for
91
assessing outcomes after knee replacement surgery. Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
J. Clin Epidimiol 1997;50(3):265-73. ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-
89 15.
Needleman J, Buerhaus PI, Mattke S, Stewart M,
Zelevinsky K. Nurse Staffing and Patient Outcomes in
92
Hospitals. Boston, MA: Health Resources Services Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Administration; 2001 February 28. Report No.:230-99- Harris DR. Quality indicators using hospital discharge
0021. data: State and national applications. Jt Comm J Qual
Improv 1998;24(2):88-195. Published erratum
90 appears in Jt Comm J Qual Improv 1998;24(6):341.
Kovner C, Gergen PJ. Nurse staffing levels and
adverse events following surgery in U.S. hospitals.
93
Image J Nurs Sch 1998;30(4):315-21. Needleman et al. 2001.

Version 2.1 46 Revision 1 (May 28, 2003)

Postoperative Sepsis

Definition Cases of sepsis per 1,000 elective surgery patients, with length of stay
more than 3 days.
Numerator Discharges with ICD-9-CM code for sepsis in any secondary diagnosis field
per 1,000 elective surgical discharge.
Denominator All elective surgical discharges defined by admit type.
Exclude patients with a principal diagnosis of infection, any code for
immunocompromised state, or cancer.
Include only patients with a length of stay of 4 days or more.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 10.1 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Summary limited to cases with a secondary diagnosis of

sepsis, and sensitivity could not be evaluated.
This indicator is intended to flag cases of Geraci et al. confirmed (by blood culture) only 2
nosocomial postoperative sepsis. This indicator of 15 episodes of sepsis or other infection
limits the code for sepsis to secondary diagnosis reported on discharge abstracts of VA patients
codes to eliminate sepsis that was present on hospitalized for CHF, COPD, or diabetes; the
admission. This indicator also excludes patients sensitivity for a positive blood culture was
who have a principal diagnosis of infection, 50%.95 In comparison with the VAs National
patients with a length of stay of less than 3 days, Surgical Quality Improvement Program
and patients with potential immunocompromised database, in which systemic sepsis is defined
states (e.g., AIDS, cancer, transplant). by a positive blood culture and systemic
manifestations of sepsis within 30 days after
Panel Review surgery, the ICD-9-CM diagnosis had a
sensitivity of 37% and a predictive value of
Panelists rated the overall usefulness of this 30%.96
indicator favorably, although they were less sure
that this complication was reflective of medical Construct validity. Needleman and Buerhaus
error. found that nurse staffing was independent of the
occurrence of sepsis among both major surgical
This indicator includes pediatric patients. High-
risk neonates are at particularly high risk for
95
catheter-related infections. Geraci JM, Ashton CM, Kuykendall DH, Johnson
ML, Wu L. In-hospital complications among survivors
Literature Review of admission for congestive heart failure, chronic
obstructive pulmonary disease, or diabetes mellitus. J
Coding validity. No evidence on validity is Gen Intern Med 1995;10(6):307-14.
available from CSP studies. Barbour reported 96
Best W, Khuri S, Phelan M, Hur K, Henderson W,
that only 38% of discharge abstracts with a Demakis J, et al. Identifying patient preoperative risk
diagnosis of sepsis actually had hospital- factors and postoperative adverse events in
acquired sepsis.94 However, this review was not administrative databases: Results from the
Department of Veterans Affairs national Surgical
94
Barbour GL. Usefulness of a discharge diagnosis of Quality Improvement Program. J Am Coll Surg
sepsis in detecting iatrogenic infection and quality of 2002;194(3):257-266.
care problems. Am J Med Qual 1993;8(1):2-5.
Version 2.1 47 Revision 1 (May 28, 2003)
or medical patients.97 Source

Empirical Analysis This indicator was originally proposed by Iezzoni

et al. as part of the Complications Screening
The project team conducted extensive empirical Program (CSP 7, septicemia).98 Needleman
analyses on the PSIs. Postoperative sepsis and Buerhaus identified sepsis as an Outcome
generally performs well on several different Potentially Sensitive to Nursing using the same
dimensions, including reliability, bias, CSP definition.99
relatedness of indicators, and persistence over
time.

Reliability. The signal ratiomeasured by the

proportion of the total variation across hospitals
that is truly related to systematic differences
(signal) in hospital performance rather than
random variation (noise)is lower than many
indicators, at 53.9%, suggesting that observed
differences in risk-adjusted rates may not reflect
true differences across hospitals.

The signal standard deviation for this indicator is

lower than many indicators, at 0.00869,
indicating that the systematic differences (signal)
among hospitals is low and less likely
associated with hospital characteristics. The
signal share is lower than many indicators, at
0.00790. The signal share is a measure of the
share of total variation (hospital and patient)
accounted for by hospitals. The lower the share,
the less important the hospital in accounting for
the rate and the more important other potential
factors (e.g., patient characteristics).

Minimum bias. The project team assessed the

effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
compared to no risk adjustment. They
measured (1) the impact of adjustment on the
assessment of relative hospital performance, (2)
the relative importance of the adjustment, (3) the
impact on hospitals with the highest and lowest
rates, and (4) the impact throughout the
distribution. The detected bias for Postoperative
sepsis is high, indicating that the measures likely
are biased based on the characteristics
observed. (It is possible that characteristics that
are not observed using administrative data may
be related to the patients risk of experiencing an
adverse event.) Risk adjustment is important for
this indicator.

97 98
Needleman J, Buerhaus PI, Mattke S, Stewart M, Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
Zelevinsky K. Nurse Staffing and Patient Outcomes in ES, Duncan C, et al. Identifying complications of care
Hospitals. Boston, MA: Health Resources Services using administrative data. Med Care 1994;32(7):700-
Administration; 2001 February 28. Report No.:230-99- 15.
0021.
99
Needleman et al., 2001.

Version 2.1 48 Revision 1 (May 28, 2003)

Postoperative Wound Dehiscence
Hospital Level Definition
Definition Cases of reclosure of postoperative disruption of abdominal wall per 1,000
cases of abdominopelvic surgery.
Numerator Discharges with ICD-9-CM code for reclosure of postoperative disruption of
abdominal wall (5461) in any secondary procedure field per 1,000 eligible
discharges.
Denominator All abdominopelvic surgical discharges.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 1.95 per 1,000 population at risk
Bias: Some bias demonstrated
Risk Adjustment Age, sex, DRG, comorbidity categories

Postoperative Wound Dehiscence

Area Level Definition
Definition Cases of reclosure of postoperative disruption of abdominal wall per
100,000 population.
Numerator Discharges with ICD-9-CM code for reclosure of postoperative disruption of
abdominal wall (5461) in any procedure field (principal or secondary) of
abdominopelvic surgical discharges.
Exclude obstetrical patients in MDC 14.
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 1.36 per 100,000 population at risk
Risk Adjustment No risk adjustment

Summary comorbidities.
This indicator is intended to flag cases of wound
dehiscence in patients who have undergone Literature Review
abdominal and pelvic surgery. This indicator is Coding validity. No evidence on validity is
defined both on a hospital level (by including available from CSP studies. Hawker et al. found
cases based on secondary diagnosis associated that the sensitivity and predictive value of wound
with the same hospitalization) and on an area dehiscence were both 100%.100 Faciszewski et
level (by including all cases of wound al. aggregated wound dehiscence with
dehiscence). postoperative hemorrhage or hematoma and
reported a pooled confirmation rate of 17% with
Panel Review 3% sensitivity of coding among patients who
Panelists suggested that postoperative wound underwent spinal fusion.101 In comparison with
disruption be excluded from the indicator and
100
that trauma, cancer, and immunocompromised Hawker BA, Coyte PC, Wright JG, Paul JE,
patients be included. They also reported that Bombardier C. Accuracy of administrative data for
the risk of developing wound dehiscence varies assessing outcomes after knee replacement surgery.
with patient factors such as age and J Clin Epidemiol 1997;50(3):265-73.
101
Faciszewski T, Johnson L, Noren C, Smith MD.

Version 2.1 49 Revision 1 (May 28, 2003)

the VAs National Surgical Quality Improvement signal share is lower than many indicators, at
Program database, in which dehiscence is 0.00171. Signal share is a measure of the share
defined as fascial disruption within 30 days after of total variation (hospital and patient) accounted
surgery, the ICD-9-CM diagnosis of wound for by hospitals. The lower the share, the less
disruption had a sensitivity of 25% and a important the hospital in accounting for the rate
predictive value of 23%.102 This code (9983) was and the more important other potential factors
ultimately removed from the accepted PSI, (e.g., patient characteristics).
because the clinical panel was concerned that
the diagnosis definition was too broad and failed Minimum bias. The project team assessed the
to distinguish skin from fascial separation. effect of age, gender, DRG, and comorbidity risk
adjustment on the relative ranking of hospitals
Construct validity. Based on two-stage review of compared to no risk adjustment. They
randomly selected deaths, Hannan et al. measured (1) the impact of adjustment on the
reported that cases with a secondary diagnosis assessment of relative hospital performance, (2)
of wound disruption were 3.0 times more likely the relative importance of the adjustment, (3) the
to have received care that departed from impact on hospitals with the highest and lowest
professionally recognized standards than cases rates, and (4) the impact throughout the
without that code (4.3% versus 1.7%), after distribution. The detected bias for Postoperative
adjusting for patient demographic, geographic, wound dehiscence is moderate, indicating that
and hospital characteristics.103 the measures may or may not be substantially
biased based on the characteristics observed.
Empirical Analysis
The project team conducted extensive empirical Source
analyses on the PSIs. Postoperative wound An indicator on this topic (9983) was originally
dehiscence generally performs well on several proposed by Hannan et al. to target cases that
different dimensions, including reliability, bias, would have a higher percentage of quality of
relatedness of indicators, and persistence over care problems than cases without the criterion,
time. as judged by medical record review.104 The
same code was included within a broader
Reliability. The signal ratiomeasured by the indicator (adverse events and iatrogenic
proportion of the total variation across hospitals complications) in AHRQs original HCUP
that is related to systematic differences (signal) Quality Indicators.105 Iezzoni et al. identified an
in hospital performance rather than random associated procedure code for reclosure of an
variation (noise)is low, at 35.6%, suggesting abdominal wall dehiscence (5461), and included
that observed differences in risk-adjusted rates both codes in the Complications Screening
may not reflect true differences across hospitals. Program.106 Miller et al. suggested the use of
both codes (as wound disruption) in the
The signal standard deviation for this indicator is original AHRQ PSI Algorithms and
lower than many indicators, at 0.00188, Groupings.107
indicating that the systematic differences (signal)
among hospitals is low and less likely
associated with hospital characteristics. The
104
Hannan et al., 1989.
Administrative databases complication coding in 105
anterior spinal fusion procedures. What does it mean? Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Spine 1995;20(16):1783-8. Harris DR. Quality indicators using hospital discharge
data: state and national applications. Jt Comm J Qual
102 Improv 1998;24(2):88-195. Published erratum
Best W, Khuri S, Phelan M, Hur K, Henderson W,
Demakis J, et al. Identifying patient preoperative risk appears in Jt Comm J Qual Improv 1998;24(6):341.
factors and postoperative adverse events in
106
administrative databases: Results from the Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
Department of Veterans Affairs national Surgical ES, Duncan C, et al. Identifying complications of care
Quality Improvement Program. J Am Coll Surg using administrative data. Med Care 1994;32(7):700-
2002;194(3):257-266. 15.
103 107
Hannan EL, Bernard HR, ODonnell JF, Kilburn H, Miller M, Elixhauser A, Zhan C, Meyer G, Patient
Jr. A methodology for targeting hospital cases for Safety Indicators: Using administrative data to identify
quality of care record reviews. Am J Public Health potential patient safety concerns. Health Services
1989;79(4):430-6. Research 2001;36(6 Part II):110-132.
Version 2.1 50 Revision 1 (May 28, 2003)
Accidental Puncture or Laceration
Hospital Level Definition
Definition Cases of technical difficulty (e.g., accidental cut or laceration during
procedure) per 1,000 discharges.
Numerator Discharges with ICD-9-CM code denoting technical difficulty (e.g.,
accidental cut, puncture, perforation, or laceration) in any secondary
diagnosis field per 1,000 discharges.
Denominator All medical and surgical discharges defined by specific DRGs.
Exclude obstetrical patients in MDC 14.
Type of Indicator Hospital level
Empirical Performance Rate: 3.29 per 1,000 population at risk
Bias: Substantial bias; should be risk-adjusted
Risk Adjustment Age, sex, DRG, comorbidity categories

Accidental Puncture or Laceration

Area Level Definition
Definition Cases of technical difficulty (e.g., accidental cut or laceration during
procedure) per 100,000 population.
Numerator Discharges with ICD-9-CM code denoting technical difficulty (e.g.,
accidental cut, puncture, perforation, or laceration) in any diagnosis field
(principal or secondary)
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 31.17 per 100,000 population at risk
Risk Adjustment No risk adjustment

Summary Literature Review

This indicator is intended to flag cases of Coding validity. No evidence on validity is

complications that arise due to technical available from CSP studies. A study of
difficulties in medical carespecifically, those laparoscopic cholecystectomy found that 95% of
involving an accidental puncture or laceration. patients with an ICD-9 code of accidental
puncture or laceration had a confirmed injury to
Panel Review the bile duct or gallbladder.108 However, only
27% had a clinically significant injury that
Panelists were unsure about how the culture of required any intervention; sensitivity of reporting
quality improvement in a hospital would affect was not evaluated. A similar study of
the coding of this complication. Some cholecystectomies reported that these two ICD-9
physicians may be reluctant to record the codes had a sensitivity of 40% and a predictive
occurrence of this complication for fear of
punishment. Panelists also noted that some of 108
these occurrences are not preventable. Taylor B. Common bile duct injury during
laparoscopic cholecystectomy in Ontario: Does ICD-9
coding indicate true incidence? CMAJ
1998;158(4):481-5.

Version 2.1 51 Revision 1 (May 28, 2003)

value of 23% in identifying bile duct injuries.109
Among 185 total knee replacement patients, Minimum bias. The project team assessed the
Hawker et al. found that the sensitivity and effect of age, gender, DRG, and comorbidity risk
predictive value of codes describing adjustment on the relative ranking of hospitals
miscellaneous mishaps during or as a direct compared to no risk adjustment. They
result of surgery (definition not given) were 86% measured (1) the impact of adjustment on the
and 55%, respectively.110 Romano et al. assessment of relative hospital performance, (2)
identified 19 of 45 episodes of accidental the relative importance of the adjustment, (3) the
puncture, laceration, or related procedure using impact on hospitals with the highest and lowest
discharge abstracts of diskectomy patients; rates, and (4) the impact throughout the
there was one false positive.111 distribution. The detected bias for Accidental
puncture or laceration is high, indicating that the
Empirical Analysis measures likely are biased based on the
characteristics observed. (It is possible that
The project team conducted extensive empirical characteristics that are not observed using
analyses on the PSIs. Accidental puncture or administrative data may be related to the
laceration generally performs well on several patients risk of experiencing an adverse event.)
different dimensions, including reliability, bias, Risk adjustment is important for this indicator.
relatedness of indicators, and persistence over
time. Source

Reliability. The signal ratiomeasured by the This indicator was originally proposed by Iezzoni
proportion of the total variation across hospitals et al. as part of the Complications Screening
that is truly related to systematic differences Program, although unlike the final PSI, its codes
(signal) in hospital performance rather than were split between two CSP indicators (CSP 27,
random variation (noise)is moderately high, technical difficulty with medical care, and
relative to other indicators, at 82.9%, suggesting sentinel events).112 It was also included as one
that observed differences in risk-adjusted rates component of a broader indicator (adverse
most likely reflect true differences across events and iatrogenic complications) in AHRQs
hospitals. original HCUP Quality Indicators.113 The
University HealthSystem Consortium adopted
The signal standard deviation for this indicator is CSP 27 as an indicator for medical (#2806) and
lower than many indicators, at 0.00279, major surgery (#2956) patients. Miller et al. also
indicating that the systematic differences (signal) split this set of ICD-9-CM codes into two broader
among hospitals is low and less likely indicators (miscellaneous misadventures and
associated with hospital characteristics. The E codes) in the original AHRQ PSI Algorithms
signal share is lower than many indicators, at and Groupings.114 Based on expert consensus
0.00241. The signal share is a measure of the panels, McKesson Health Solutions included
share of total variation (hospital and patient) one component of this PSI (Accidental Puncture
accounted for by hospitals. The lower the share, or Laceration) in its CareEnhance Resource
the less important the hospital in accounting for Management Systems, Quality Profiler
the rate and the more important other potential Complications Measures Module.
factors (e.g., patient characteristics).
109 112
Valinsky LJ, Hockey RI, Hobbs MS, Fletcher DR, Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
Pikora TJ, Parsons RW, et al. Finding bile duct ES, Duncan C, et al. Identifying complications of care
injuries using record linkage: A validated study of using administrative data. Med Care 1994;32(7):700-
complications following cholecystectomy. J Clin 15.
Epidemiol 1999;52(9):893-901.
113
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
110
Hawker GA, Coyte PC, Wright JG, Paul JE, Harris DR. Quality indicators using hospital discharge
Bombardier C. Accuracy of administrative data for data: State and national applications. Jt Comm J Qual
assessing outcomes after knee replacement surgery. Improv 1998;24(2):88-195. Published erratum
J Clin Epidemiol 1997;50(3):265-73. appears in Jt Comm J Qual Improv 1998;24(6):341.
111 114
Romano P. Can administrative data be used to Miller M, Elixhauser A, Zhan C, Meyer G, Patient
ascertain clinically significant postoperative Safety Indicators: Using administrative data to identify
complications. American Journal of Medical Quality potential patient safety concerns. Health Services
Press. Research 2001;36(6 Part II):110-132.
Version 2.1 52 Revision 1 (May 28, 2003)
Transfusion Reaction
Hospital Level Definition
Definition Cases of transfusion reaction per 1,000 discharges.
Numerator Discharges with ICD-9-CM code for transfusion reaction in any secondary
diagnosis field per 1,000 discharges.
Denominator All medical and surgical discharges defined by specific DRGs.
Type of Indicator Hospital level
Area level
Empirical Performance Rate: 0.01 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment No risk adjustment

Transfusion Reaction
Area Level Definition
Definition Cases of transfusion reaction per 100,000 population.
Numerator Discharges with ICD-9-CM code for transfusion reaction in any diagnosis
field (principal or secondary ) of all medical and surgical discharges defined
by specific DRGs.
Denominator Population of county or MSA associated with FIPS code of patients
residence or hospital location.
Type of Indicator Area level
Empirical Performance Rate: 0.05 per 100,000 population
Risk Adjustment No risk adjustment

Summary Literature Review

This indicator is intended to flag cases of major The project team was unable to find evidence on
reactions due to transfusions (ABO and Rh). validity from prior studies, most likely because
This indicator is defined both on a hospital level this complication is quite rare.
(by including cases based on secondary
diagnosis associated with the same Empirical Analysis
hospitalization) and on an area level (by
including all cases of transfusion reactions). The project team conducted extensive empirical
analyses on the PSIs. Given the low rates or
Panel Review occurrences for Transfusion reaction, the project
team did not measure reliability or minimum
The overall usefulness of this indicator was bias. The indicator could not be risk-adjusted
rated as very favorable by panelists. This due to the small number of numerator cases.
indicator includes only those events that result in Users of the PSI software should note the output
additional medical care. Some minor reactions will only contain observed rates for Transfusion
may be missed, although the panel suggested reaction.
that these minor reactions are less clearly due to
medical error than the Rh or ABO reactions Source
included in the indicator.
This indicator was originally proposed by Iezzoni

Version 2.1 53 Revision 1 (May 28, 2003)

et al. as part of the Complications Screening
Program (CSP sentinel events).115 It was also
included as one component of a broader
indicator (adverse events and iatrogenic
complications) in AHRQs original HCUP
Quality Indicators.116 It was proposed by Miller et
al. in the original AHRQ PSI Algorithms and
Groupings. 117

115
Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher
ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-
15.
116
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Harris DR. Quality indicators using hospital discharge
data: State and national applications. Jt Comm J Qual
Improv 1998;24(2):88-195. Published erratum
appears in Jt Comm J Qual Improv 1998;24(6):341.
117
Miller M, Elixhauser A, Zhan C, Meyer G, Patient
safety indicators: Using administrative data to identify
potential patient safety concerns. Health Services
Research 2001;36(6 Part II):110-132.
Version 2.1 54 Revision 1 (May 28, 2003)
Birth TraumaInjury to Neonate

Definition Cases of birth trauma per 1,000 liveborn births.

Numerator Discharges with ICD-9-CM code for birth trauma in any diagnosis field per
1,000 liveborn births.
Denominator All liveborn births.
Exclude infants with a subdural or cerebral hemorrhage (subgroup of birth
trauma coding) and any diagnosis code of pre-term infant (denoting birth
weight of less than 2,500 grams and less than 37 weeks gestation or 34
weeks gestation or less).
Exclude infants with injury to skeleton (7673, 7674) and any diagnosis code
of osteogenesis imperfecta (75651).
Type of Indicator Hospital level
Empirical Performance Rate: 6.34 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment Sex

Summary data sets.119

This indicator is intended to flag cases of birth Empirical Analysis

trauma for infants born alive in a hospital. The
indicator excludes patients born pre-term, as The project team conducted extensive empirical
birth trauma in these patients may be less analyses on the PSIs. Birth trauma generally
preventable than for full-term infants. performs well on several different dimensions,
including reliability, relatedness of indicators,
Panel Review and persistence over time.

The overall usefulness of this indicator was Reliability. The signal ratiomeasured by the
rated as favorable by panelists proportion of the total variation across hospitals
that is truly related to systematic differences
Literature Review (signal) in hospital performance rather than
random variation (noise)is high, relative to
Coding validity. A study of newborns who had a other indicators, at 97.0%, suggesting that
discharge diagnosis of birth trauma found that observed differences in risk-adjusted rates
only 25% had sustained a significant injury to reflect true differences across hospitals.
the head, neck, or shoulder.118 The remaining
patients either had superficial injuries or injuries The signal standard deviation for this indicator is
inferior to the neck. The project team was also high, relative to other indicators, at 0.04128,
unable to find other evidence on the validity of indicating that the systematic differences (signal)
this indicator. Towner et al. linked California among hospitals is high and more likely
maternal and infant discharge abstracts from associated with hospital characteristics. The
1992 through 1994, but they used only infant signal share is also high, relative to other
discharge abstracts to describe the incidence of indicators, at 0.13603. The signal share is a
neonatal intracranial injury, and they did not measure of the share of total variation (hospital
report the extent of agreement between the two and patient) accounted for by hospitals. The

118 119
Hughes C, Harley E, Milmoe G, Bala R, Martorella Towner D, Castro MA, Eby-Wilkens E, Gilbert
A. Birth trauma in the head and neck. Arch WM. Effect of mode of delivery in nulliparous women
Otolaryngol Head Neck Surg 1999;125:193-199. on neonatal intracranial injury. N Engl J Med
1999;341(23):1709-14.
Version 2.1 55 Revision 1 (May 28, 2003)
lower the share, the less important the hospital
in accounting for the rate and the more
important other potential factors (e.g., patient
characteristics).

Minimum bias. The bias for Birth trauma was

not measured, since adequate risk adjustment
was not available..

Source

This indicator has been widely used in the

obstetric community, although it is most
commonly based on chart review rather than
administrative data. It was proposed by Miller et
al. in the original AHRQ PSI Algorithms and
Groupings.120 Based on expert consensus
panels, McKesson Health Solutions included a
broader version of this indicator in its
CareEnhance Resource Management Systems,
Quality Profiler Complications Measures
Module.

120
Miller M, Elixhauser A, Zhan C, Meyer G, Patient
Safety Indicators: Using administrative data to identify
potential patient safety concerns. Health Services
Research 2001;36(6 Part II):110-132.

Version 2.1 56 Revision 1 (May 28, 2003)

Obstetric TraumaCesarean Delivery

Definition Cases of obstetric trauma (4th degree lacerations, other obstetric

lacerations) per 1,000 Cesarean deliveries.
Numerator Discharges with ICD-9-CM code for obstetric trauma in any diagnosis or
procedure field per 1,000 Cesarean deliveries.
Denominator All Cesarean delivery discharges.
Type of Indicator Hospital level
Empirical Performance Rate: 5.93 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment Age

Summary Reliability. The signal ratiomeasured by the

proportion of the total variation across hospitals
This indicator is intended to flag cases of that is truly related to systematic differences
potentially preventable trauma during Cesarean (signal) in hospital performance rather than
delivery. random variation (noise)is lower than many
indicators, at 45.9%, suggesting that observed
Panel Review differences in risk-adjusted rates may not reflect
true differences across hospitals.
The overall usefulness of an Obstetric trauma
indicator was rated as favorable by panelists. The signal standard deviation for this indicator is
After initial review, the indicator was eventually also lower than many indicators, at 0.00590,
split into three separate Obstetric trauma indicating that the systematic differences (signal)
indicators: Vaginal delivery with instrument, among hospitals is low and less likely
Vaginal delivery without instrument, and associated with hospital characteristics. The
Cesarean delivery. signal share is lower than many indicators, at
0.00576. The signal share is a measure of the
Literature Review share of total variation (hospital and patient)
accounted for by hospitals. The lower the share,
Coding validity. In a stratified probability sample the less important the hospital in accounting for
of vaginal and Cesarean deliveries, the weighted the rate and the more important other potential
sensitivity and predictive value of coding for factors (e.g., patient characteristics).
third- and fourth-degree lacerations and
vulvar/perineal hematomas (based on either Minimum bias. The bias for Obstetric
diagnosis or procedure codes) were 89% and traumaCesarean delivery was not measured,
90%, respectively.158 The authors did not report since adequate risk adjustment was not
coding validity for third- and fourth-degree available..
lacerations separately. The project team was
unable to find other evidence on validity from Source
prior studies.
An overlapping subset of this indicator (third- or
Empirical Analysis fourth-degree perineal laceration) has been
adopted by the Joint Commission for the
The project team conducted extensive empirical Accreditation of Healthcare Organizations
analyses on the PSIs. Obstetric (JCAHO) as a core performance measure for
traumaCesarean delivery generally performs pregnancy and related conditions (PR-25).
well on several different dimensions, including Based on expert consensus panels, McKesson
reliability, relatedness of indicators, and Health Solutions included the JCAHO indicator
persistence over time. in its CareEnhance Resource Management
Systems, Quality Profiler Complications

Version 2.1 57 Revision 1 (May 28, 2003)

Measures Module. Fourth degree laceration,
one of the codes mapped to this PSI, was
included as one component of a broader
indicator (obstetrical complications) in AHRQs
original HCUP Quality Indicators.121

121
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Harris DR. Quality indicators using hospital discharge
data: State and national applications. Jt Comm J Qual
Improv 1998;24(2):88-195. Published erratum
appears in Jt Comm J Qual Improv 1998;24(6):341.
Version 2.1 58 Revision 1 (May 28, 2003)
Obstetric TraumaVaginal Delivery with Instrument

Definition Cases of obstetric trauma (4th degree lacerations, other obstetric

lacerations) per 1,000 instrument-assisted vaginal deliveries.
Numerator Discharges with ICD-9-CM code for obstetric trauma in any diagnosis or
procedure field per 1,000 instrument-assisted vaginal deliveries.
Denominator All vaginal delivery discharges with any procedure code for instrument-
assisted delivery.
Type of Indicator Hospital level
Empirical Performance Rate: 235.7 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment Age

Summary
Reliability. The signal ratiomeasured by the
This indicator is intended to flag cases of proportion of the total variation across hospitals
potentially preventable trauma during vaginal that is truly related to systematic differences
delivery with instrument. (signal) in hospital performance rather than
random variation (noise)is moderately high,
Panel Review relative to other indicators, at 69.9%, suggesting
that observed differences in risk-adjusted rates
The overall usefulness of an Obstetric trauma likely reflect true differences across hospitals.
indicator was rated as favorable by panelists.
After initial review, the indicator was eventually The signal standard deviation for this indicator is
split into three separate Obstetric trauma also high, relative to other indicators, at 0.09794,
indicators: Vaginal delivery with instrument, indicating that the systematic differences (signal)
Vaginal delivery without instrument, and among hospitals is high and more likely
Cesarean delivery. associated with hospital characteristics. The
signal share is high, relative to other indicators,
Literature Review at 0.05539. The signal share is a measure of the
share of total variation (hospital and patient)
Coding validity. In a stratified probability sample accounted for by hospitals. The lower the share,
of vaginal and Cesarean deliveries, the weighted the less important the hospital in accounting for
sensitivity and predictive value of coding for the rate and the more important other potential
third- and fourth-degree lacerations and factors (e.g., patient characteristics).
vulvar/perineal hematomas (based on either
diagnosis or procedure codes) were 89% and Minimum bias. The bias for Obstetric
90%, respectively.158 The authors did not report traumavaginal delivery with instrument was
coding validity for third- and fourth-degree not measured, since adequate risk adjustment
lacerations separately. The project team was was not available..
unable to find other evidence on validity from
prior studies. Source

Empirical Analysis An overlapping subset of this indicator (third- or

fourth-degree perineal laceration) has been
The project team conducted extensive empirical adopted by the Joint Commission for the
analyses on the PSIs. Obstetric Accreditation of Healthcare Organizations
traumavaginal delivery with instrument (JCAHO) as a core performance measure for
generally performs well on several different pregnancy and related conditions (PR-25).
dimensions, including reliability, relatedness of Based on expert consensus panels, McKesson
indicators, and persistence over time. Health Solutions included the JCAHO indicator

Version 2.1 59 Revision 1 (May 28, 2003)

in its CareEnhance Resource Management
Systems, Quality Profiler Complications
Measures Module. Fourth degree laceration,
one of the codes mapped to this PSI, was
included as one component of a broader
indicator (obstetrical complications) in AHRQs
original HCUP Quality Indicators.122

122
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Harris DR. Quality indicators using hospital discharge
data: State and national applications. Jt Comm J Qual
Improv 1998;24(2):88-195. Published erratum
appears in Jt Comm J Qual Improv 1998;24(6):341.
Version 2.1 60 Revision 1 (May 28, 2003)
Obstetric TraumaVaginal Delivery without Instrument

Definition Cases of obstetric trauma (4th degree lacerations, other obstetric

lacerations) per 1,000 vaginal deliveries without instrument assistance.
Numerator Discharges with ICD-9-CM code for obstetric trauma in any diagnosis or
procedure field per 1,000 vaginal deliveries without instrument assistance.
Denominator All vaginal delivery discharges.
Exclude instrument-assisted delivery.
Type of Indicator Hospital level
Empirical Performance Rate: 85.1 per 1,000 population at risk
Bias: Did not undergo empirical testing of bias
Risk Adjustment Age

Summary indicators, and persistence over time.

This indicator is intended to flag cases of Reliability. The signal ratiomeasured by the
potentially preventable trauma during a vaginal proportion of the total variation across hospitals
delivery without instrument. that is truly related to systematic differences
(signal) in hospital performance rather than
Panel Review random variation (noise)is high, relative to
other indicators, at 86.4%, suggesting that
The overall usefulness of an Obstetric trauma observed differences in risk-adjusted rates
indicator was rated as favorable by panelists. reflect true differences across hospitals.
After initial review, the indicator was split into
three separate Obstetric trauma indicators: The signal standard deviation for this indicator is
Vaginal delivery with instrument, Vaginal also high, relative to other indicators, at 0.04314,
delivery without instrument, and Cesarean indicating that the systematic differences (signal)
delivery. among hospitals is high and more likely
associated with hospital characteristics. The
Literature Review signal share is lower than many other indicators,
at 0.02470. The signal share is a measure of the
Coding validity. In a stratified probability sample share of total variation (hospital and patient)
of vaginal and Cesarean deliveries, the weighted accounted for by hospitals. The lower the share,
sensitivity and predictive value of coding for the less important the hospital in accounting for
third- and fourth-degree lacerations and the rate and the more important other potential
vulvar/perineal hematomas (based on either factors (e.g., patient characteristics).
diagnosis or procedure codes) were 89% and
90%, respectively.158 The authors did not report Minimum bias. The bias for Obstetric
coding validity for third- and fourth-degree traumavaginal delivery without instrument was
lacerations separately. The project team was not measured, since adequate risk adjustment
unable to find other evidence on validity from was not available.
prior studies.
Source
Empirical Analysis
An overlapping subset of this indicator (third- or
The project team conducted extensive empirical fourth-degree perineal laceration) has been
analyses on the PSIs. Obstetric adopted by the Joint Commission for the
traumavaginal delivery without instrument Accreditation of Healthcare Organizations
generally performs well on several different (JCAHO) as a core performance measure for
dimensions, including reliability, relatedness of pregnancy and related conditions (PR-25).

Version 2.1 61 Revision 1 (May 28, 2003)

Based on expert consensus panels, McKesson
Health Solutions included the JCAHO indicator
in its CareEnhance Resource Management
Systems, Quality Profiler Complications
Measures Module. Fourth-degree laceration,
one of the codes mapped to this PSI, was
included as one component of a broader
indicator (obstetrical complications) in AHRQs
original HCUP Quality Indicators.123

123
Johantgen M, Elixhauser A, Bali JK, Goldfarb M,
Harris DR. Quality indicators using hospital discharge
data: State and national applications. Jt Comm J Qual
Improv 1998;24(2):88-195. Published erratum
appears in Jt Comm J Qual Improv 1998;24(6):341.
Version 2.1 62 Revision 1 (May 28, 2003)
References

Ball JK, Elixhauser A, Johantgen M, et al. HCUP Quality Indicators, Methods, Version 1.1: Outcome,
Utilization, and Access Measures for Quality Improvement. (AHCPR Publication No. 98-0035).
Healthcare Cost and Utilization project (HCUP-3) Research notes: Rockville, MD: Agency for Health
Care Policy and Research, 1998.

Barbour GL. Usefulness of a discharge diagnosis of sepsis in detecting iatrogenic infection and quality of
care problems. Am J Med Qual 1993;8(1):2-5.

Berlowitz D, Brand H, Perkins C. Geriatric syndromes as outcome measures of hospital care: Can
administrative data be used? JAGS 1999;47:692-696.

Best W, Khuri S, Phelan M, Hur K, Henderson W, Demakis J, et al. Identifying patient preoperative risk
factors and postoperative adverse events in administrative databases: Results from the Department
of Veterans Affairs National Surgical Quality Improvement Program. J Am Coll Surg 2002;194(3):257-
266.

Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events
and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J
Med 1991;324(6):370-6.

Christiansen CL, Morris CN. Improving the statistical approach to health care provider profiling. Ann Intern
Med 1997;127(8 Pt 2):764-8).

Davies S, Geppert J, McClellan M, McDonald KM, Romano PS, Shojania KG. Refinement of the HCUP
Quality Indicators. Technical Review Number 4. Rockville, MD: (Prepared by UCSF-Stanford
Evidence-based Practice Center under Contract No. 290-97-0013) Agency for Healthcare Research
and Quality; 2001. Report No.: 01-0035.

EMBASE. In. The Netherlands: Elsevier Science Publishers B.V.

Envisioning the National Health Care Quality Report. Washington, DC: Institute of Medicine; 2001.

Faciszewski T, Johnson L, Noren C, Smith MD. Administrative databases complication coding in anterior
spinal fusion procedures. What does it mean? Spine 1995;20(16):1783-8.

Fitch K, Bernstein J, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, et al. the RAND/UCLA
Appropriateness Method Users Manual: RAND; 2001.

Geraci JM, Ashton CM, Kuykendall DH, Johnson ML, Wu L. In-hospital complications among survivors of
admission for congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus. J
Gen Intern Med 1995;10(6):307-14.

Geraci JM, Ashton CM, Kuykendall DH, Johnson ML, Wu L. International Classification of Diseases, 9th
Revision, Clinical Modification codes in discharge abstracts are poor measures of complication
occurrence in medical inpatients. Med Care 1997;35(6):589-602.

Green L, Lewis F. measurement and Evaluation in Health Education and Health Promotion. Mountain
View, CA: Mayfield Publishing Company; 1998.

Hannan EL, Bernard HR, ODonnell JF, Kilburn H, Jr. A methodology for targeting hospital cases for
quality of care record reviews. Am J Public Health 1989;79(4):430-6.

Hartz AJ, Kuhn EM. Comparing hospitals that perform coronary artery bypass surgery: The effect of
outcome measures and data sources. Am J Public Health 1994;84(10):1609-14.

Version 2.1 63 Revision 1 (May 28, 2003)

Hawker BA, Coyte PC, Wright JG, Paul JE, Bombardier C. Accuracy of administrative data for assessing
outcomes after knee replacement surgery. J Clin Epidemiol 1997;50(3):265-73.

Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of
individual physician report cards for assessing the costs and quality of care of a chronic disease
JAMA 1999;281(22):2098-105.

Hughes C, Harley E, Milmoe G, Bala R, Martorella A. Birth trauma in the head and neck. Arch Otolaryngol
Head Neck Surg 1999;125:193-199.

Iezzoni L, Lawthers A, Petersen L, McCarthy E, Palmer R, Cahalane M, et al. Project to validate the
Complications Screening Program: Health Care Financing Administration; 1998 March 31. Report No:
HCFA Contract 500-94-0055.

Iezzoni LI, Daley J, Heeren T, Foley SM, Fisher ES, Duncan C, et al. Identifying complications of care
using administrative data. Med Care 1994;32(7):700-15.

Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamel MB, Mukamal K, et al. Does the Complications
Screening Program flag cases with process of care problems? Using explicit criteria to judge
processes. Int J Qual Health Care 1999;11(2):107-18.

Iezzoni LI, Foley SM, Heeren T, Daley J, Duncan CC, Fisher ES, et al. A method for screening the quality
of hospital care using administrative data: preliminary validation results. QRB Qual Rev Bull
1992;18(11):361-71.

Impact: Case Studies Notebook Documented Impact and Use of AHRQ's Research. Compiled by
Division of Public Affairs, Office of Health Care Information, Agency for Healthcare Research and
Quality.

Institute of Medicine. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson
MS (eds.) Washington DC: National Academy Press, 2000.

Johantgen M, Elixhauser A, Bali JK, Goldfarb M, Harris DR. Quality indicators using hospital discharge
data: state and national applications. Jt Comm J Qual Improv 1998;24(2):88-105.

Johantgen M, Elixhauser A, Bali JK, Goldfarb M, Harris DR. Quality indicators using hospital discharge
data: state and national applications. Jt Comm J Qual Improv 1998;24(2):88-195. Published erratum
appears in Jt Comm J Qual Improv 1998;24(6):341.

Keeler E, Kahn K, Bentow S. Assessing quality of care for hospitalized Medicare patients with hip fracture
using coded diagnoses from the Medicare Provider Analysis and Review file. Springfield, VA: NTIS;
1991.

Kovner C, Gergen PH. Nurse staffing levels and adverse events following surgery in U.S. hospitals.
Image J Nurs Sch 1998;30(4):315-21.

Lawthers A, McCarthy E, Davis R, Peterson L, Palmer R, Iezzoni L. Identification of in-hospital

complications from claims data: is it valid? Medical Care 2000;38(8):785-795.

Lichtig LK, Knauf RA, Hilholland DK. Some impacts of nursing on acute care hospital outcomes. J Nurs
Adm 1999;29(2):25-33.

McCarthy EP, Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamael MB, et al. Does clinical evidence
support ICD-9-CM diagnosis coding of complications? Med Care 2000;38(8);868-876.

Measuring the Quality of Health Care: A statement of the National Roundtable on Healthcare Quality

Version 2.1 64 Revision 1 (May 28, 2003)

 Division of Healthcare Services: National Academy Press; 1999.

MEDLINE [database online]. In. Bethesda (MD): National Library of Medicine.

Miller M, Elixhauser A, Zhan C, Meyer G, Patient Safety Indicators: Using administrative data to identify
potential patient safety concerns. Health Services Research 2001;36(6 Part II):110-132.

National Roundtable on Healthcare Quality, 1999.

Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. Nurse Staffing and Patient Outcomes in
Hospitals. Boston, MA: Health Resources Services Administration; 2001 February 28. Report No.:
230-88-0021.

Nursing-Sensitive Quality Indicators for Acute Care Settings and ANAs Safety & Quality Initiative. In:
American Nurses Association; 1999.

Romano P. Can administrative data be used to ascertain clinically significant postoperative complications.
American Journal of Medical Quality Press.

Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making health care safer: A critical analysis of
patient safety practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University
of California at San Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-
0013). Rockville, MD: Agency for Healthcare Research and Quality; 2001. Report No.: AHRQ
Publication No. 01-E058.

Silber J, Rosenbaum P, Ross R. Comparing the contributions of groups of predictors: Which outcomes
vary with hospital rather than patient characteristics? J Am Stat Assoc 1995;90:7-18.

Silber JH, Rosenbaum PR, Williams SV, Ross RN, Schwartz JS. The relationship between choice of
outcome measure and hospital rank in general surgical procedures: Implications for quality
assessment. Int J Qual Health Care 1997;9(3):193-200.

Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with
death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992;30(7):615-
29.

Taylor B. Common bile duct injury during laparoscopic cholecystectomy in Ontario: Does ICD-9 coding
indicate true incidence? CMAJ 1998;158(4):481-5.

Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on
neonatal intracranial injury. N Engl J Med 1999;341(23):1709-14.

Valinsky LJ, Hockey RI, Hobbs MS, Fletcher DR, Pikora TJ, Parsons RW, et al. Finding bile duct injuries
using record linkage: A validated study of complications following cholecystectomy. J Clin Epidemiol
1999;52(9):893-901.

Weingart SN, Iezzoni LI, Davis RB, Palmer RH, Cahalane M, Hamel MB, et al. Use of administrative data
to find substandard care: Validation of the Complications Screening Program. Med Care
2000;38(8):796-806.

White RH, Romano P, Zhou H, Rodrigo J, Barger W. Incidence and time course of thromboembolic
outcomes following total hip or knee arthroplasty. Arch Intern Med 1998;158(14):1525-31.

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Appendix A: Patient Safety Indicators Detailed Definitions

Complications of Anesthesia
Numerator:
Discharges with ICD-9-CM diagnosis codes for anesthesia complications in any secondary
diagnosis field per 1,000 discharges.

Anesthesia Complications
ICD-9-CM diagnosis codes:

E8763 Endotracheal tube wrongly place during anesthetic procedure

E8551 Accidental poisoning, Other nervous system depressants

Adverse effects in therapeutic use, other central nervous system depressants and anesthetics:
E9381 Halothane
E9382 Other gaseous anesthetics
E9383 Intravenous anesthetics
E9384 Other and unspecified general anesthetics
E9385 Surface and infiltration anesthetics
E9386 Peripheral nerve and plexus blocking anesthetics
E9387 Spinal anesthetics
E9389 Other and unspecified local anesthetics

Poisoning by other central nervous system depressants and anesthetics:

968.1 Halothane
968.2 Other gaseous anesthetics
968.3 Intravenous anesthetics
968.4 Other and unspecified general anesthetics
968.7 Spinal anesthetics

Denominator:
All surgical discharges defined by specific DRGs.

Surgical Discharges
DRGs:

001 Craniotomy, age greater than 17 except for trauma

002 Craniotomy for trauma, age greater than 17
003 Craniotomy, age 0-17
004 Spinal procedures
005 Extracranial vascular procedures
006 Carpal tunnel release
007 Peripheral and cranial nerve and other nervous system procedures with CC
008 Peripheral and cranial nerve and other nervous system procedures without CC
036 Retinal procedures
037 Orbital procedures
038 Primary iris procedures
039 Lens procedures with or without vitrectomy
040 Extraocular procedures except orbit, age greater than 17
041 Extraocular procedures except orbit, age 0-17
042 Intraocular procedures except retina, iris and lens
049 Major head and neck procedures
050 Sialoadenectomy
051 Salivary gland procedures except sialoadenectomy
052 Cleft lip and palate repair
053 Sinus and mastoid procedures, age greater than 17

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054 Sinus and mastoid procedures, age 0-17
055 Miscellaneous ear, nose, mouth and throat procedures
056 Rhinoplasty
057 Tonsillectomy and adenoidectomy procedures except tonsillectomy and/or adenoidectomy only, age greater
than 17
058 Tonsillectomy and adenoidectomy procedures except tonsillectomy and/or adenoidectomy only, age 0-17
059 Tonsillectomy and/or adenoidectomy only, age greater than 17
060 Tonsillectomy and/or adenoidectomy only, age 0 - 17
061 Myringotomy with tube insertion, age greater than 17
062 Myringotomy with tube insertion, age 0-17
063 Other ear, nose, mouth and throat OR procedures
075 Major chest procedures
076 Other respiratory system OR procedures with CC
077 Other respiratory system OR procedures without CC
103 Heart transplant
104 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization
105 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization
106 Coronary bypass with PTCA
107 Coronary bypass with cardiac catheterization
108 Other cardiothoracic procedures
109 Coronary bypass without cardiac catheterization
110 Major cardiovascular procedures with CC
111 Major cardiovascular procedures without CC
112 Percutaneous cardiovascular procedures
113 Amputation for circulatory system disorders except upper limb and toe
114 Upper limb and toe amputation for circulatory site
115 Permanent cardiac pacemaker implant with acute myocardial infarction, heart failure or shock or AICD lead or
generator procedure
116 Other permanent cardiac pacemaker implant or PTCA with coronary arterial stent
117 Cardiac pacemaker revision except device replacement
118 Cardiac pacemaker device replacement
119 Vein ligation and stripping
120 Other circulatory system OR procedures
146 Rectal resection with CC
147 Rectal resection without CC
148 Major small and large bowel procedures with CC
149 Major small and large bowel procedures without CC
150 Peritoneal adhesiolysis with CC
151 Peritoneal adhesiolysis without CC
152 Minor small and large bowel procedures with CC
153 Minor small and large bowel procedures without CC
154 Stomach, esophageal and duodenal procedures, age greater than 17 with CC
155 Stomach, esophageal and duodenal procedures, age greater than 17 without CC
156 Stomach, esophageal and duodenal procedures, age 0-17
157 Anal and stomal procedures with CC
158 Anal and stomal procedures without CC
159 Hernia procedures except inguinal and femoral, age greater than 17 with CC
160 Hernia procedures except inguinal and femoral, age greater than 17 without CC
161 Inguinal and femoral hernia procedures, age greater than 17 with CC
162 Inguinal and femoral hernia procedures, age greater than 17 without CC
163 Hernia procedures, age 0-17
164 Appendectomy with complicated principal diagnosis with CC
165 Appendectomy with complicated principal diagnosis without CC
166 Appendectomy without complicated principal diagnosis with CC
167 Appendectomy without complicated principal diagnosis without CC
168 Mouth procedures with CC
169 Mouth procedures without CC
170 Other digestive system OR procedures with CC
171 Other digestive system OR procedures without CC
191 Pancreas, liver and shunt procedures with CC
192 Pancreas, liver and shunt procedures without CC
193 Biliary tract procedures except only cholecystectomy with or without common duct exploration with CC

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Complications of Anesthesia
194 Biliary tract procedures except only cholecystectomy with or without common duct exploration without CC
195 Cholecystectomy with common duct exploration with CC
196 Cholecystectomy with common duct exploration without CC
197 Cholecystectomy except by laparoscope without common duct exploration with CC
198 Cholecystectomy except by laparoscope without common duct exploration without CC
199 Hepatobiliary diagnostic procedure for malignancy
200 Hepatobiliary diagnostic procedure for nonmalignancy
201 Other hepatobiliary or pancreas OR procedures
209 Major joint and limb reattachment procedures of lower extremity
210 Hip and femur procedures except major joint procedures, age greater than 17 with CC
211 Hip and femur procedures except major joint procedures, age greater than 17 without CC
212 Hip and femur procedures except major joint procedure, age 0-17
213 Amputation for musculoskeletal system and connective tissue disorders
214 No longer valid
215 No longer valid
216 Biopsies of musculoskeletal system and connective tissue
217 Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders
218 Lower extremity and humerus procedures except hip, foot and femur, age greater than 17 with CC
219 Lower extremity and humerus procedures except hip, foot and femur, age greater than 17 without CC
220 Lower extremity and humerus procedures except hip, foot and femur, age 0-17
221 No longer valid
222 No longer valid
223 Major shoulder/elbow procedures or other upper extremity procedures with CC
224 Shoulder, elbow or forearm procedures except major joint procedures without CC
225 Foot procedures
226 Soft tissue procedures with CC
227 Soft tissue procedures without CC
228 Major thumb or joint procedures or other hand or wrist procedures with CC
229 Hand or wrist procedures except major joint procedures without CC
230 Local excision and removal of internal fixation devices of hip and femur
231 Local excision and removal of internal fixation devices except hip and femur
232 Arthroscopy
233 Other musculoskeletal system and connective tissue OR procedures with CC
234 Other musculoskeletal system and connective tissue OR procedures without CC
257 Total mastectomy for malignancy with CC
258 Total mastectomy for malignancy without CC
259 Subtotal mastectomy for malignancy with CC
260 Subtotal mastectomy for malignancy without CC
261 Breast procedure for nonmalignancy except biopsy and local excision
262 Breast biopsy and local excision for nonmalignancy
263 Skin graft and/or debridement for skin ulcer or cellulitis with CC
264 Skin graft and/or debridement for skin ulcer or cellulitis without CC
265 Skin graft and/or debridement except for skin ulcer or cellulitis with CC
266 Skin graft and/or debridement except for skin ulcer or cellulitis without CC
267 Perianal and pilonidal procedures
268 Skin, subcutaneous tissue and breast plastic procedures
269 Other skin, subcutaneous tissue and breast procedures with CC
270 Other skin, subcutaneous tissue and breast procedures without CC
285 Amputation of lower limb for endocrine, nutritional and metabolic disorders
286 Adrenal and pituitary procedures
287 Skin grafts and wound debridements for endocrine, nutritional and metabolic disorders
288 OR procedures for obesity
289 Parathyroid procedures
290 Thyroid procedures
291 Thyroglossal procedures
292 Other endocrine, nutritional and metabolic OR procedures with CC
293 Other endocrine, nutritional and metabolic OR procedures without CC
302 Kidney transplant
303 Kidney, ureter and major bladder procedures for neoplasm
304 Kidney, ureter and major bladder procedures for nonneoplasms with CC
305 Kidney, ureter and major bladder procedures for nonneoplasms without CC
306 Prostatectomy with CC

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Complications of Anesthesia
307 Prostatectomy without CC
308 Minor bladder procedures with CC
309 Minor bladder procedures without CC
310 Transurethral procedures with CC
311 Transurethral procedures without CC
312 Urethral procedures, age greater than 17 with CC
313 Urethral procedures, age greater than 17 without CC
314 Urethral procedures, age 0-17
315 Other kidney and urinary tract OR procedures
334 Major male pelvic procedures with CC
335 Major male pelvic procedures without CC
336 Transurethral prostatectomy with CC
337 Transurethral prostatectomy without CC
338 Testes procedures for malignancy
339 Testes procedures for nonmalignancy, age greater than 17
340 Testes procedures for nonmalignancy, age 0-17
341 Penis procedures
342 Circumcision, age greater than 17
343 Circumcision, age 0-17
344 Other male reproductive system OR procedures for malignancy
345 Other male reproductive system OR procedures except for malignancy
353 Pelvic evisceration, radical hysterectomy and radical vulvectomy
354 Uterine and adnexa procedures for nonovarian/adnexal malignancy with CC
355 Uterine and adnexa procedures for nonovarian/adnexa procedures without CC
356 Female reproductive system reconstructive procedures
357 Uterine and adnexa procedures for ovarian or adnexal malignancy
358 Uterine and adnexa procedures for nonmalignancy with CC
359 Uterine and adnexa procedures for nonmalignancy without CC
360 Vagina, cervix and vulva procedures
361 Laparoscopy and incisional tubal interruption
362 Endoscopic tubal interruption
363 D and C, conization and radioimplant for malignancy
364 D and C, conization except for malignancy
365 Other female reproductive system OR procedures
370 Cesarean section with CC
371 Cesarean section without CC
374 Vaginal delivery with sterilization and/or D and C
375 Vaginal delivery with OR procedure except sterilization and/or D and C
377 Postpartum and postabortion diagnoses with OR procedure
381 Abortion with D and C aspiration curettage or hysterectomy
392 Splenectomy, age greater than 17
393 Splenectomy, age 0-17
394 Other OR procedures of the blood and blood-forming organs
400 Lymphoma and leukemia with major OR procedures
401 Lymphoma and nonacute leukemia with other OR procedure with CC
402 Lymphoma and nonacute leukemia with other OR procedure without CC
406 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedures with CC
407 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedures without CC
408 Myeloproliferative disorders or poorly differentiated neoplasms with other OR procedures
415 OR procedure for infectious and parasitic diseases
424 OR procedures with principal diagnosis of mental illness
439 Skin grafts for injuries
440 Wound debridements for injuries
441 Hand procedures for injuries
442 Other OR procedures for injuries with CC
443 Other OR procedures for injuries without CC
458 No longer valid
459 No longer valid
461 OR procedures with diagnoses of other contact with health services
468 Extensive OR procedure unrelated to principal diagnosis
471 Bilateral or multiple major joint procedures of lower extremity
472 No longer valid

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Complications of Anesthesia
476 Prostatic OR procedure unrelated to principal diagnosis
477 Nonextensive OR procedure unrelated to principal diagnosis
478 Other vascular procedures with CC
479 Other vascular procedures without CC
480 Liver transplant
481 Bone marrow transplant
482 Tracheostomy for face, mouth and neck diagnoses
483 Tracheostomy except for face, mouth and neck diagnoses
484 Craniotomy for multiple significant trauma
485 Limb reattachment, hip and femur procedures for multiple significant trauma
486 Other OR procedures for multiple significant trauma
488 HIV with extensive OR procedure
491 Major joint and limb reattachment procedures of upper extremity
493 Laparoscopic cholecystectomy without common duct exploration with CC
494 Laparoscopic cholecystectomy without common duct exploration without CC
495 Lung transplant
496 Combined anterior/posterior spinal fusion
497 Spinal fusion with CC
498 Spinal fusion without CC
499 Back and neck procedures except spinal fusion with CC
500 Back and neck procedures except spinal fusion without CC
501 Knee procedures with principal diagnosis of infection, with CC
502 Knee procedures with principal diagnosis of infection, without CC
503 Knee procedures without principal diagnosis of infection
504 Extensive 3rd degree burns with skin graft
506 Full thickness burn with skin graft or inhalation injury with CC or significant trauma
507 Full thickness burn with skin graft or inhalation injury without CC or significant trauma
512 Simultaneous pancreas/kidney transplant
513 Pancreas transplant
514 Cardiac defibrillator implant with cardiac catheterization
515 Cardiac defibrillator implant without cardiac catheterization
516 Percutaneous cardiovascular procedure with AMI
517 Percutaneous cardiovascular procedure with non-drug eluting stent without AMI
518 Percutaneous cardiovascular procedure without coronary artery stent or AMI
519 Cervical spinal fusion with CC
520 Cervical spinal fusion without CC
525 Heart assist system implant
526 Percutaneous cardiovascular procedure with drug eluting stent with AMI
527 Percutaneous cardiovascular procedure with drug eluting stent without AMI

Exclude:
Patients with codes for poisoning due to anesthetics (E8551, 9681-4, 9687) and any diagnosis
code for active drug dependence, active nondependent abuse of drugs, or self-inflicted injury.

Active Drug Dependence

ICD-9-CM diagnosis codes:

30400 Opioid type dependence - unspecified

30401 Opioid type dependence - continuous
30402 Opioid type dependence - episodic
30410 Barbiturate and similarly acting sedative or hypnotic dependence - unspecified
30411 Barbiturate and similarly acting sedative or hypnotic dependence - continuous
30412 Barbiturate and similarly acting sedative or hypnotic dependence - episodic
30420 Cocaine dependence - unspecified
30421 Cocaine dependence - continuous
30422 Cocaine dependence - episodic
30430 Cannabis dependence - unspecified
30431 Cannabis dependence - continuous
30432 Cannabis dependence - episodic
30440 Amphetamine and other psycho stimulant dependence - unspecified

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Complications of Anesthesia
30441 Amphetamine and other psycho stimulant dependence - continuous
30442 Amphetamine and other psycho stimulant dependence - episodic
30450 Hallucinogen dependence - unspecified
30451 Hallucinogen dependence - continuous
30452 Hallucinogen dependence - episodic
30460 Other specified drug dependence - unspecified
30461 Other specified drug dependence - continuous
30462 Other specified drug dependence - episodic
30470 Combinations of opioid type drug with any other - unspecified
30471 Combinations of opioid type drug with any other - continuous
30472 Combinations of opioid type drug with any other - episodic
30480 Combinations of drug excluding opioid type drug - unspecified
30481 Combinations of drug excluding opioid type drug - continuous
30482 Combinations of drug excluding opioid type drug - episodic
30490 Unspecified drug dependence - unspecified
30491 Unspecified drug dependence - continuous
30492 Unspecified drug dependence - episodic

Active Nondependent Abuse of Drugs

ICD-9-CM diagnosis codes:

30520 Cannabis abuse - unspecified

30521 Cannabis abuse - continuous
30522 Cannabis abuse - episodic
30530 Hallucinogen abuse - unspecified
30531 Hallucinogen abuse - continuous
30532 Hallucinogen abuse - episodic
30540 Barbiturate and similarly acting sedative or hypnotic abuse - unspecified
30541 Barbiturate and similarly acting sedative or hypnotic abuse - continuous
30542 Barbiturate and similarly acting sedative or hypnotic abuse - episodic
30550 Opioid abuse - unspecified
30551 Opioid abuse - continuous
30552 Opioid abuse - episodic
30560 Cocaine abuse - unspecified
30561 Cocaine abuse - continuous
30562 Cocaine abuse - episodic
30570 Amphetamine or related acting sympathomimetic abuse - unspecified
30571 Amphetamine or related acting sympathomimetic abuse - continuous
30572 Amphetamine or related acting sympathomimetic abuse - episodic
30580 Antidepressant type abuse - unspecified
30581 Antidepressant type abuse - continuous
30582 Antidepressant type abuse - episodic
30590 Other, mixed, or unspecified drug abuse - unspecified
30591 Other, mixed, or unspecified drug abuse - continuous
30592 Other, mixed, or unspecified drug abuse - episodic

Self-Inflicted Injury
ICD-9-CM diagnosis codes:

Suicide and self-inflicted poisoning by solid or liquid substance:

E9500 Analgesics, antipyretics, and antirheumatics
E9501 Barbiturates
E9502 Other sedative and hypnotics
E9503 Tranquilizers and other psychotropic agents
E9504 Other specified drugs and medicinal substances
E9505 Unspecified drug or medicinal substance
E9506 Agricultural and horticultural chemical and pharmaceutical preparations other than plant foods and fertilizers
E9507 Corrosive and caustic substances
E9508 Arsenic and its compounds
E9509 Other and unspecified solid and liquid substances

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Complications of Anesthesia
Suicide and self-inflicted poisoning by gases in domestic use:
E9510 Gas distributed by pipeline
E9511 Liquefied petroleum gas distributed in mobile containers
E9518 Other utility gases

Suicide and self-inflicted poisoning by other gases and vapors:

E9520 Motor vehicle exhaust gas
E9521 Other carbon monoxide
E9528 Other specified gases and vapors
E9529 Unspecified gases and vapors

Suicide and self-inflicted injury by hanging, strangulation, and suffocation:

E9530 Hanging
E9531 Suffocation by plastic bag
E9538 Other specified means
E954 Suicide and self-inflicted injury by submersion [drowning]

Suicide and self-inflicted injury by firearms and explosives:

E9550 Handgun
E9551 Shotgun
E9552 Hunting rifle
E9553 Military firearms
E9554 Other and unspecified firearms
E9555 Explosives
E9559 Unspecified

E956 Suicide and self inflicted injury by cutting and piercing instrument

Suicide and self-inflicted injury by jumping from a high place:

E9570 Residential premises
E9571 Other man-made structures
E9572 Natural sites
E9579 Unspecified

Suicide and self-inflicted injury by other and unspecified means:

E9580 Jumping or lying before moving object
E9581 Burns, fire
E9582 Scald
E9583 Extremes of cold
E9584 Electrocution
E9585 Crashing of motor vehicle
E9586 Crashing of aircraft
E9587 Caustic substances except poisoning
E9588 Other specified means
E9589 Unspecified means

Death in Low-Mortality DRGs

Numerator:
All discharges with disposition of deceased per 1,000 population at risk.
Denominator:
All discharges in DRGs with less than 0.5% mortality rate, based on NIS 1997 low-mortality DRG.
If a DRG is divided into without/with complications, both DRGs must have mortality rates below
0.5% to qualify for inclusion.

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Death in Low-Mortality DRGs
Low-Mortality DRGs
DRGs:

015 Transient ischemic attack and precerebral occlusions

021 Viral meningitis
026 Seizure and headache, age 0-17
030 Traumatic stupor and coma, coma less than one hour, age 0-17
031 Concussion, age greater than 17 with CC
032 Concussion, age greater than 17 without CC
033 Concussion, age 0-17
036 Retinal procedures
037 Orbital procedures
042 Intraocular procedures
044 Acute major eye infections
045 Neurological eye disorders
050 Sialoadenectomy
052 Cleft lip and palate repair
053 Sinus and mastoid procedures, age greater than 17
055 Misc ear, nose, mouth and throat procedures
057 Tonsillectomy and adenoidectomy procedures except tonsillectomy and/or adenoidectomy only, age greater
than 17
060 Tonsillectomy and/or adenoidectomy only, age 0-17
062 Myringotomy with tube insertion, age 0-17
063 Other ear, nose, mouth and throat or procedures
065 Dysequilibrium
068 Otitis media and URI, age greater than 17 with CC
070 Otitis media and URI, age 0-17
071 Laryngotracheitis
074 Other ear, nose, mouth and throat diagnoses, age 0-17
091 Simple pneumonia and pleurisy, age 0-17
096 Bronchitis and asthma, age greater than 17 with CC
097 Bronchitis and asthma, age greater than 17 without CC
098 Bronchitis and asthma, age 0-17
125 Circulatory disorders except acute myocardial infarction with cardiac catheterization without complex diagnosis
134 Hypertension
140 Angina pectoris
141 Syncope and collapse with CC
142 Syncope and collapse without CC
143 Chest pain
156 Stomach, esophageal and duodenal procedures, age 0-17
163 Hernia procedures, age 0-17
166 Appendectomy without complicated principal diagnosis with CC
167 Appendectomy without complicated principal diagnosis without CC
184 Esophagitis, gastroenteritis and misc digestive disorders, age 0-17
190 Other digestive system diagnoses, age 0-17
212 Hip and femur procedures except major joint procedures, age 0-17
218 Lower extremity and humerus procedures except hip, foot and femur, age greater than 17 with CC
219 Lower extremity and humerus procedures except hip, foot and femur, age greater than 17 without CC
220 Lower extremity and humerus procedures except hip, foot and femur, age 0-17
223 Major shoulder, elbow procedures or other upper extremity procedures with CC
224 Shoulder, elbow or forearm procedures except major joint procedures without CC
225 Foot procedures
228 Major thumb or joint procedures or other hand or wrist procedures with CC
229 Hand or wrist procedures except major joint procedures without CC
232 Arthroscopy
237 Sprains, strains and dislocations of hip, pelvis and thigh
243 Medical back problems
246 Nonspecific arthropathies
252 Fractures, sprains, strains and dislocations of forearm, hand and foot, age 0-17
255 Fractures, sprains, strains and dislocations of upper arm and lower leg except foot, age 0-17
257 Total mastectomy for malignancy with CC

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Death in Low-Mortality DRGs
258 Total mastectomy for malignancy without CC
261 Breast procedure for nonmalignancy except biopsy and local excision
262 Breast biopsy and local excision of nonmalignancy
267 Perianal and pilonical procedures
279 Cellulitis, age 0-17
282 Trauma to skin, subcutaneous tissue and breast, age 0-17
289 Parathyroid procedures
290 Thyroid procedures
293 Other endocrine, nutritional and metabolic or procedures without CC
295 Diabetes, age 0-35
298 Nutritional and misc metabolic disorders, age greater than 17 without CC
317 Admission for renal dialysis
322 Kidney and urinary tract infection, age 0-17
323 Urinary stones with CC and/or esw lithotripsy
324 Urinary stones without CC
333 Other kidney and urinary tract diagnoses, age 0-17
334 Major male pelvic procedures with CC
335 Major male pelvic procedures without CC
336 Transurethral prostatectomy with CC
337 Transurethral prostatectomy without CC
351 Sterilization, male
356 Female reproduction system reconstructive procedures
358 Uterine and adnexa procedures for nonmalignancy with CC
359 Uterine and adnexa procedures for nonmalignancy without CC
360 Vagina, cervix and vulva procedures
361 Laparoscopy and incisional tubal interruption
362 Endoscopic tubal interruption
364 D and C, conization except for malignancy
369 Menstrual and other female reproductive system disorders
370 Cesarean section with CC
371 Cesarean section without CC
372 Vaginal delivery with complicating diagnoses
373 Vaginal delivery without complicating diagnoses
374 Vaginal delivery with sterilization and/or d and c
375 Vaginal delivery with or procedure except sterilization and/or d and c
377 Postpartum and postabortion diagnoses with or procedure
378 Ectopic pregnancy
379 Threatened abortion
380 Abortion without D and C
381 Abortion with D and C, aspiration curettage or hysterotomy
382 False labor
383 Other antepartum diagnoses with medical complications
384 Other antepartum diagnoses without medical complications
393 Splenectomy, age 0-17
396 Red blood cell disorders, age 0-17
421 Viral illness, age greater than 17
422 Viral illness and fever of unknown origin, age 0-17
425 Acute adjustment reactions and disturbances of psychosocial dysfunction
426 Depressive neuroses
427 Neuroses except depressive
428 Disorders of personality and impulse control
431 Childhood mental disorders
432 Other mental disorder diagnoses
434 Alcohol/drug abuse or dependence, detoxification or other symptomatic treatment with CC
435 Alcohol/drug abuse or dependence, detoxification or other symptomatic treatment without CC
436 Alcohol/drug dependence with rehabilitation therapy
439 Skin grafts for injuries
441 Hand procedures for injuries
446 Traumatic injury, age 0-17
448 Allergic reactions, age 0-17
451 Poisoning and toxic effects of drugs, age 0-17
491 Major joint and limb reattachment procedures of upper extremity

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Death in Low-Mortality DRGs
499 Back and neck procedures except spinal fusion with CC
500 Back and neck procedures except spinal fusion without CC

Exclude:
Patients with any code for trauma, immunocompromised state, or cancer.

Trauma
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

800 Fracture of vault of skull

801 Fracture of base of skull
802 Fracture of face bones
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones
805 Fracture of vertebral column without mention of spinal cord injury
806 Fracture of vertebral column with spinal cord injury
807 Fracture of rib[s] sternum, larynx, and trachea
808 Fracture of pelvis
809 Ill-defined fractures of bones of trunk
810 Fracture of clavicle
811 Fracture of scapula
812 Fracture of humerus
813 Fracture of radius and ulna
814 Fracture of carpal bone[s]
815 Fracture of metacarpal bone[s]
817 Multiple fracture of hand bones
818 Ill-defined fractures of upper limb
819 Multiple fractures involving both upper limbs, and upper limb with rib and sternum
820 Fracture of neck of femur
821 Fracture of other and unspecified parts of femur
822 Fracture of patella
823 Fracture of tibia and fibula
824 Fracture of ankle
825 Fracture of one or more tarsal and metatarsal bones
827 Other, multiple, and ill-defined fractures of lower limb
828 Multiple fractures involving both lower limbs, lower with upper limb, and lower limb with rib and sternum
829 Fracture of unspecified bones
830 Dislocation of jaw
831 Dislocation of shoulder
832 Dislocation of elbow
833 Dislocation of wrist
835 Dislocation of hip
836 Dislocation of knee
837 Dislocation of ankle
838 Dislocation of foot
839 Other, multiple, and ill-defined dislocations
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following injury
853 Other and unspecified intracranial hemorrhage following injury
854 Intracranial injury of other and unspecified nature
860 Traumatic pneumothorax
861 Injury to heart and lung
862 Injury to other and unspecified intrathoracic organs
863 Injury to gastrointestinal tract
864 Injury to liver
865 Injury to spleen
866 Injury to kidney
867 Injury to pelvic organs
868 Injury to other intra-abdominal organs
869 Internal injury to unspecified or ill-defined organs

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Death in Low-Mortality DRGs
870 Open wound of ocular adnexa
871 Open wound of eyeball
872 Open wound of ear
873 Other open wound of head
874 Open wound of neck
875 Open wound of chest [wall]
876 Open wound of back
877 Open wound of buttock
878 Open wound of genital organs [external] including traumatic amputation
879 Open wound of other and unspecified sites, except limbs
880 Open wound of shoulder and upper arm
881 Open wound of elbow, forearm, and wrist
882 Open wound of hand except finger alone
884 Multiple and unspecified open wound of upper limb
887 Traumatic amputation of arm and hand (complete) (partial)
890 Open wound of hip and thigh
891 Open wound of knee, leg (except thigh) and ankle
892 Open wound of foot except toe alone
894 Multiple and unspecified open wound of lower limb
896 Traumatic amputation of foot (complete) (partial)
897 Traumatic amputation of leg[s] (complete) (partial)
900 Injury to blood vessels of head and neck
901 Injury to blood vessels of thorax
902 Injury to blood vessels of abdomen and pelvis
903 Injury to blood vessels of upper extremity
904 Injury to blood vessels of lower extremity and unspecified sites
925 Crushing injury of face, scalp, and neck
926 Crushing injury of trunk
927 Crushing injury of upper limb
928 Crushing injury of lower limb
929 Crushing injury of multiple and unspecified sites
940 Burn confined to eye and adnexa
941 Burn of face, head, and neck
942 Burn of trunk
943 Burn of upper limb, except wrist and hand
944 Burn of wrist[s] and hand[s]
945 Burn of lower limb[s]
946 Burns of multiple specified sites
947 Burn of internal organs
948 Burns classified according to extent of body surface involved
949 Burn, unspecified
952 Spinal chord injury without evidence of spinal bone injury
953 Injury to nerve roots and spinal plexus
958 Certain early complications of trauma

DRGs:

002 Craniotomy for trauma, age greater than 17

027 Traumatic stupor and coma, coma greater than one hour
028 Traumatic stupor and coma, coma less than one hour, age greater than 17 with CC
029 Traumatic stupor and coma, coma less than one hour, age greater than 17 without CC
030 Traumatic stupor and coma, coma less than one hour, age 0-17
031 Concussion, age greater than 17 with CC
032 Concussion, age greater than 17 without CC
033 Concussion, age 0-17
072 Nasal trauma and deformity
083 Major chest trauma with CC
084 Major chest trauma without CC
235 Fractures of femur
236 Fracture of hip and pelvis
237 Sprains, strains and dislocations of hip, pelvis and thigh
440 Wound debridements for injuries

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441 Hand procedures for injuries
442 Other OR procedures for injuries with CC
443 Other OR procedures for injuries without CC
444 Traumatic injury, age greater than 17 with CC
445 Traumatic injury, age greater than 17 without CC
446 Traumatic injury, age 0-17
456 No longer valid
457 No longer valid
458 No longer valid
459 No longer valid
460 No longer valid
484 Craniotomy for multiple significant trauma
485 Limb reattachment, hip and femur procedures for multiple significant trauma
486 Other OR procedures for multiple significant trauma
487 Other multiple significant traumas
491 Major joint and limb reattachment procedures of upper extremity
504 Total hepatectomy
505 Extensive 3rd degree burns w/o skin graft
506 Full thickness burn with skin graft or inhalation injury with CC or significant trauma
507 Full thickness burn with skin graft or inhalation injury without CC or significant trauma
508 Full thickness burn without skin graft or inhalation injury with CC or significant trauma
509 Full thickness burn without skin graft or inhalation injury without CC or significant trauma
510 Non-extensive burns with CC or significant trauma
511 Non-extensive burns without CC or significant trauma

Immunocompromised States
ICD-9-CM diagnosis codes:

042 Human immunodeficiency virus disease

1363 Pneumocystosis
27900 Hypogammaglobulinemia NOS
27901 Selective IgA immunodeficiency
27902 Selective IgM immunodeficiency
27903 Other selective immunoglobulin deficiencies
27904 Congenital hypogammaglobulinemia
27905 Immunodeficiency with increased IgM
27906 Common variable immunodefiency
27909 Humoral immunity deficiency NEC
27910 Immunodeficiency with predominant T-cell defect, NOS
27911 DiGeorges syndrome
27912 Wiskott-Aldrich syndrome
27913 Nezelofs syndrome
27919 Deficiency of cell-mediated immunity, NOS
2792 Combined immunity deficiency
2793 Unspecified immunity deficiency
2794 Autoimmune disease, not elsewhere classified
2798 Other specified disorders involving the immune mechanism
2799 Unspecified disorder of immune mechanism

Complications of transplanted organ:

9968 Complications of transplanted organ
99680 Transplanted organ, unspecified
99681 Kidney transplant
99682 Liver transplant
99683 Heart transplant
99684 Lung transplant
99685 Bone marrow transplant
99686 Pancreas transplant
99687 Intestine transplant
99689 Other specified organ transplant
V420 Kidney replaced by transplant
V421 Heart replaced by transplant

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V426 Lung replaced by transplant
V427 Liver replaced by transplant
V428 Other specified organ or tissue
V4281 Bone marrow replaced by transplant
V4282 Peripheral stem cells replaced by transplant
V4283 Pancreas replaced by transplant
V4284 Intestines replace by transplant
V4289 Other replaced by transplant

ICD-9-CM procedure codes:

335 Lung transplantation

3350 Lung transplantation, NOS
3351 Unilateral lung transplantation
3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
375 Heart transplantation
410 Operations on bone marrow and spleen
4100 Bone marrow transplant, NOS
4101 Autologous bone marrow transplant without purging
4102 Allogeneic bone marrow transplant with purging
4103 Allogeneic bone marrow transplant without purging
4104 Autologous hematopoietic stem cell transplant without purging
4105 Allogeneic hematopoietic stem cell transplant without purging
4106 Cord blood stem cell transplant
4107 Autologous hematopoietic stem cell transplant with purging
4108 Allogeneic hematopoietic stem cell transplant with purging
4109 Autologous bone marrow transplant with purging
5051 Auxiliary liver transplant
5059 Liver transplant, NEC
5280 Pancreatic transplant, NOS
5281 Reimplantation of pancreatic tissue
5282 Homotransplant of pancreas
5283 Heterotransplant of pancreas
5285 Allotransplantation of cells of islets of Langerhans
5286 Transplantation of cells of islets of Langerhans, NOS
5569 Other kidney transplantation

Cancer
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

140 Malignant neoplasm of lip

141 Malignant neoplasm of tongue
142 Malignant neoplasm of major salivary glands
143 Malignant neoplasm of gum
144 Malignant neoplasm of floor of mouth
145 Malignant neoplasm of other and unspecified parts of mouth
146 Malignant neoplasm of oropharynx
147 Malignant neoplasm of nasopharynx
148 Malignant neoplasm of hypopharynx
149 Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
150 Malignant neoplasm of esophagus
151 Malignant neoplasm of stomach
152 Malignant neoplasm of small intestine, including duodenum
153 Malignant neoplasm of colon
154 Malignant neoplasm of rectum, rectosigmoid junction, and anus
155 Malignant neoplasm of liver and intrahepatic bile ducts
156 Malignant neoplasm of gallbladder and extrahepatic bile ducts
157 Malignant neoplasm of pancreas
158 Malignant neoplasm of retroperitoneum and peritoneum
159 Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum

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160 Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
161 Malignant neoplasm of larynx
162 Malignant neoplasm of trachea, bronchus, and lung
163 Malignant neoplasm of pleura
164 Malignant neoplasm of thymus, heart, and mediastinum
165 Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170 Malignant neoplasm of bone and articular cartilage
171 Malignant neoplasm of connective and other soft tissue
172 Malignant melanoma of skin
174 Malignant neoplasm of female breast
175 Malignant neoplasm of male breast
176 Karposis sarcoma
179 Malignant neoplasm of uterus, part unspecified
180 Malignant neoplasm of cervix uteri
181 Malignant neoplasm of eye
182 Malignant neoplasm of body of uterus
183 Malignant neoplasm of ovary and other uterine adnexa
184 Malignant neoplasm of other and unspecified female genital organs
185 Malignant neoplasm of other and unspecified female genital organs
186 Malignant neoplasm of testes
187 Malignant neoplasm of penis and other male genital organs
188 Malignant neoplasm of bladder
189 Malignant neoplasm of kidney and other and unspecified urinary organs
190 Malignant neoplasm of eye
191 Malignant neoplasm of brain
192 Malignant neoplasm of other and unspecified parts of nervous system
193 Malignant neoplasm of thyroid gland
194 Malignant neoplasm of other endocrine glands and related structures
195 Malignant neoplasm of other, and ill-defined sites
196 Secondary and unspecified malignant neoplasm of lymph nodes
197 Secondary malignant neoplasm of respiratory and digestive systems
198 Secondary malignant neoplasm of other specified sites
199 Malignant neoplasm without specification of site
200 Lymphosarcoma and reticulosarcoma
201 Hodgkins disease
202 Other malignant neoplasms of lymphoid and histiocytic tissues
203 Multiple myeloma and immunoproliferative neoplasms
204 Lymphoid leukemia
205 Myeloid leukemia
206 Monocytic leukemia
207 Other specified leukemia
208 Leukemia of unspecified cell type
2386 Neoplasm of uncertain behavior of other and unspecified sites and tissues, plasma cells
2733 Macroglobulinemia

Personal history of malignant neoplasm:

V1000 Gastrointestinal tract, unspecified
V1001 Tongue
V1002 Other and unspecified oral cavity and pharynx
V1003 Esophagus
V1004 Stomach
V1005 Large intestine
V1006 Rectum, rectosigmoid junction, and anus
V1007 Liver
V1009 Other
V1011 Bronchus and lung
V1012 Trachea
V1020 Respiratory organ, unspecified
V1021 Larynx
V1022 Nasal cavities, middle ear, and accessory sinuses
V1029 Other respiratory and intrathoracic organs, other
V103 Breast

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V1040 Female genital organ, unspecified
V1041 Cervix uteri
V1042 Other parts of uterus
V1043 Ovary
V1044 Other female genital organs
V1045 Male genital organ, unspecified
V1046 Prostate
V1047 Testes
V1048 Epididymis
V1049 Other male genital organs
V1050 Urinary organ, unspecified
V1051 Bladder
V1052 Kidney
V1053 Renal pelvis
V1059 Urinary organs, other
V1060 Leukemia, unspecified
V1061 Lymphoid leukemia
V1062 Myeloid leukemia
V1063 Monocytic leukemia
V1069 Leukemia, other
V1071 Lymphosarcoma and reticulosarcoma
V1072 Hodgkins disease
V1079 Other lymphatic and hematopoietic neoplasms, other
V1081 Bone
V1082 Malignant melanoma of skin
V1083 Other malignant neoplasm of skin
V1084 Eye
V1085 Brain
V1086 Other parts of nervous system
V1087 Thyroid
V1088 Other endocrine glands and related structures
V1089 Other
V109 Unspecified personal history of malignant neoplasm

DRGs:

010 Nervous system neoplasms with CC

011 Nervous system neoplasms without CC
064 Ear, nose, mouth and throat malignancy
082 Respiratory neoplasms
172 Digestive malignancy with CC
173 Digestive malignancy without CC
199 Hepatobiliary diagnostic procedure for malignancy
203 Malignancy of hepatobiliary system or pancreas
239 Pathological fractures and musculoskeletal and connective tissue malignancy
257 Total mastectomy for malignancy with CC
258 Total mastectomy for malignancy without CC
259 Subtotal mastectomy for malignancy with CC
260 Subtotal mastectomy for malignancy without CC
274 Malignant breast disorders with CC
275 Malignant breast disorders without CC
303 Kidney, ureter and major bladder procedures for neoplasm
318 Kidney and urinary tract neoplasms with CC
319 Kidney and urinary tract neoplasms without CC
338 Testes procedures for malignancy
344 Other male reproductive system OR procedures for malignancy
346 Malignancy of male reproductive system with CC
347 Malignancy of male reproductive system without CC
354 Uterine and adnexa procedures for nonovarian/adnexal malignancy with CC
355 Uterine and adnexa procedures for nonovarian/adnexal malignancy without CC
357 Uterine and adnexa procedures for ovarian or adnexal malignancy
363 D and C, conization and radioimplant for malignancy

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367 Malignancy of female reproductive system without CC
400 Lymphoma and leukemia with major OR procedures
401 Lymphoma and nonacute leukemia with other OR procedure with CC
402 Lymphoma and nonacute leukemia with other OR procedure without CC
403 Lymphoma and nonacute leukemia with CC
404 Lymphoma and nonacute leukemia without CC
405 Acute leukemia without major or procedure, age 0-17
406 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedures with CC
407 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedure without CC
408 Myeloproliferative disorders or poorly differentiated neoplasms with other OR procedures
409 Radiotherapy
410 Chemotherapy without acute leukemia as secondary diagnosis
411 History of malignancy without endoscopy
412 History of malignancy with endoscopy
413 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses with CC
414 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses without CC
473 Acute leukemia without major OR procedure, age greater than 17
492 Chemotherapy with acute leukemia as secondary diagnosis

Decubitus Ulcer
Numerator:
Discharges with ICD-9-CM code of 7070 in any secondary diagnosis field per 1,000 discharges.
Denominator:
All medical and surgical discharges defined by specific DRGs (see denominator for
Complications of Anesthesia for surgical discharges).

Medical Discharges
DRGs:

009 Spinal disorders and injuries

010 Nervous system neoplasms with CC
011 Nervous system neoplasms without CC
012 Degenerative nervous system disorders
013 Multiple sclerosis and cerebellar ataxia
014 Specific cerebrovascular disorders except transient ischemic attack
015 Transient ischemic attack and precerebral occlusions
016 Nonspecific cerebrovascular disorders with CC
017 Nonspecific cerebrovascular disorders without CC
018 Cranial and peripheral nerve disorders with CC
019 Cranial and peripheral nerve disorders without CC
020 Nervous system infection except viral meningitis
021 Viral meningitis
022 Hypertensive encephalopathy
023 Nontraumatic stupor and coma
024 Seizure and headache, age greater than 17 with CC
025 Seizure and headache, age greater than 17 without CC
026 Seizure and headache, age 0-17
027 Traumatic stupor and coma, coma greater than one hour
028 Traumatic stupor and coma, coma less than one hour, age greater than 17 with CC
029 Traumatic stupor and coma, coma less than one hour, age greater than 17 without CC
030 Traumatic stupor and coma, coma less than one hour, age 0-17
031 Concussion, age greater than 17 with CC
032 Concussion, age greater than 17 without CC
033 Concussion, age 0-17

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034 Other disorders of nervous system with CC
035 Other disorders of nervous system without CC
043 Hyphema
044 Acute major eye infections
045 Neurological eye disorders
046 Other disorders of the eye, age greater than 17 with CC
047 Other disorders of the eye, age greater than 17 without CC
048 Other disorders of the eye, age 0-17
064 Ear, nose, mouth and throat malignancy
065 Disequilibria
066 Epistaxis
067 Epiglotitis
068 Otitis media and URI, age greater than 17 with CC
069 Otitis media and URI, age greater than 17 without CC
070 Otitis media and URI, age 0-17
071 Laryngotracheitis
072 Nasal trauma and deformity
073 Other ear, nose, mouth and throat diagnoses, age greater than 17
074 Other ear, nose, mouth and throat diagnoses, age 0-17
078 Pulmonary embolism
079 Respiratory infections and inflammations, age greater than 17 with CC
080 Respiratory infections and inflammations, age greater than 17 without CC
081 Respiratory Infections and Inflammations, age 0-17
082 Respiratory neoplasms
083 Major chest trauma with CC
084 Major chest trauma without CC
085 Pleural effusion with CC
086 Pleural effusion without CC
087 Pulmonary edema and respiratory failure
088 Chronic obstructive pulmonary disease
089 Simple pneumonia and pleurisy, age greater than 17 with CC
090 Simple pneumonia and pleurisy, age greater than 17 without CC
091 Simple pneumonia and pleurisy, age 0-17
092 Interstitial lung disease with CC
093 Interstitial lung disease without CC
094 Pneumothorax with CC
095 Pneumothorax without CC
096 Bronchitis and asthma, age greater than 17 with CC
097 Bronchitis and asthma, age greater than 17 without CC
098 Bronchitis and asthma, age 0-17
099 Respiratory signs and symptoms with CC
100 Respiratory signs and symptoms without CC
101 Other respiratory system diagnoses with CC
102 Other respiratory system diagnoses without CC
121 Circulatory disorders with acute myocardial infarction and major complication, discharged alive
122 Circulatory disorders with acute myocardial infarction without major complication, discharged alive
123 Circulatory disorders with acute myocardial infarction, expired
124 Circulatory disorders except acute myocardial infarction with cardiac catheterization and complex diagnosis
125 Circulatory disorders except acute myocardial infarction with cardiac catheterization without complex
diagnosis
126 Acute and subacute endocarditis
127 Heart failure and shock
128 Deep vein thrombophlebitis
129 Cardiac arrest, unexplained
130 Peripheral vascular disorders with CC
131 Peripheral vascular disorders without CC
132 Atherosclerosis with CC
133 Atherosclerosis without CC
134 Hypertension
135 Cardiac congenital and valvular disorders, age greater than 17 with CC
136 Cardiac congenital and valvular disorders, age greater than 17 without CC
137 Cardiac congenital and valvular disorders, age 0-17

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138 Cardiac arrhythmia and conduction disorders with CC
139 Cardiac arrhythmia and conduction disorders without CC
140 Angina pectoris
141 Syncope and collapse with CC
142 Syncope and collapse without CC
143 Chest pain
144 Other circulatory system diagnoses with CC
145 Other circulatory system diagnoses without CC
172 Digestive malignancy with CC
173 Digestive malignancy without CC
174 GI hemorrhage with CC
175 GI hemorrhage without CC
176 Complicated peptic ulcer
177 Uncomplicated peptic ulcer with CC
178 Uncomplicated peptic ulcer without CC
179 Inflammatory bowel disease
180 GI obstruction with CC
181 GI obstruction without CC
182 Esophagitis, gastroenteritis and miscellaneous digestive disorders, age greater than 17 with CC
183 Esophagitis, gastroenteritis and miscellaneous digestive disorders, age greater than 17 without CC
184 Esophagitis, gastroenteritis and miscellaneous digestive disorders, age 0-17
185 Dental and oral diseases except extractions and restorations, age greater than 17
186 Dental and oral diseases except extractions and restorations, age 0-17
187 Dental extractions and restorations
188 Other digestive system diagnoses, age greater than 17 with CC
189 Other digestive system diagnoses, age greater than 17 without CC
190 Other digestive system diagnoses, age 0-17
202 Cirrhosis and alcoholic hepatitis
203 Malignancy of hepatobiliary system or pancreas
204 Disorders of pancreas except malignancy
205 Disorders of liver except malignancy, cirrhosis and alcoholic hepatitis with CC
206 Disorders of liver except malignancy, cirrhosis and alcoholic hepatitis without CC
207 Disorders of the biliary tract with CC
208 Disorders of the biliary tract without CC
235 Fractures of femur
236 Fractures of hip and pelvis
237 Sprains, strains and dislocations of hip, pelvis and thigh
238 Osteomyelitis
239 Pathological fractures and musculoskeletal and connective tissue malignancy
240 Connective tissue disorders with CC
241 Connective tissue disorders without CC
242 Septic arthritis
243 Medical back problems
244 Bone diseases and specific arthropathies with CC
245 Bone diseases and specific arthropathies without CC
246 Nonspecific arthropathies
247 Signs and symptoms of musculoskeletal system and connective tissue
248 Tendonitis, myositis and bursitis
249 Aftercare, musculoskeletal system and connective tissue
250 Fractures, sprains, strains and dislocations of forearm, hand and foot, age greater than 17 with CC
251 Fractures, sprains, strains and dislocations of forearm, hand and foot, age greater than 17 without CC
252 Fractures, sprains, strains and dislocations of forearm, hand and foot, age 0-17
253 Fractures, sprains, strains and dislocations of upper arm and lower leg except foot, age greater than 17 with
CC
254 Fractures, sprains, strains and dislocations of upper arm and lower leg except foot, age greater than 17
without CC
255 Fractures, sprains, strains and dislocations of upper arm and lower leg except foot, age 0-17
256 Other musculoskeletal system and connective tissue diagnoses
271 Skin ulcers
272 Major skin disorders with CC
273 Major skin disorders without CC
274 Malignant breast disorders with CC

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275 Malignant breast disorders without CC
276 Nonmalignant breast disorders
277 Cellulitis, age greater than 17 with CC
278 Cellulitis, age greater than 17 without CC
279 Cellulitis, age 0-17
280 Trauma to skin, subcutaneous tissue and breast, age greater than 17 with CC
281 Trauma to skin, subcutaneous tissue and breast, age greater than 17 without CC
282 Trauma to skin, subcutaneous tissue and breast, age 0-17
283 Minor skin disorders with CC
284 Minor skin disorders without CC
294 Diabetes, age greater than 35
295 Diabetes, age 0-35
296 Nutritional and miscellaneous metabolic disorders, age greater than 17 with CC
297 Nutritional and miscellaneous metabolic disorders, age greater than 17 without CC
298 Nutritional and miscellaneous metabolic disorders, age 0-17
299 Inborn errors of metabolism
300 Endocrine disorders with CC
301 Endocrine disorders without CC
316 Renal failure
317 Admission for renal dialysis
318 Kidney and urinary tract neoplasms with CC
319 Kidney and urinary tract neoplasms without CC
320 Kidney and urinary tract infections, age greater than 17 with CC
321 Kidney and urinary tract infections, age greater than 17 without CC
322 Kidney and urinary tract infection, age 0-17
323 Urinary stones with CC and/or ESW lithotripsy
324 Urinary stones without CC
325 Kidney and urinary tract signs and symptoms, age greater than 17 with CC
326 Kidney and urinary tract signs and symptoms, age greater than 17 without CC
327 Kidney and urinary tract signs and symptoms, age 0-17
328 Urethral stricture, age greater than 17 with CC
329 Urethral stricture, age greater than 17 without CC
330 Urethral stricture, age 0-17
331 Other kidney and urinary tract diagnoses, age greater than 17 with CC
332 Other kidney and urinary tract diagnoses, age greater than 17 without CC
333 Other kidney and urinary tract diagnoses, age 0-17
346 Malignancy of male reproductive system with CC
347 Malignancy of male reproductive system without CC
348 Benign prostatic hypertrophy with CC
349 Benign prostatic hypertrophy without CC
350 Inflammation of the male reproductive system
351 Sterilization, male
352 Other male reproductive system diagnoses
366 Malignancy of female reproductive system with CC
367 Malignancy of female reproductive system without CC
368 Infections of female reproductive system
369 Menstrual and other female reproductive system disorders
372 Vaginal delivery with complicating diagnoses
373 Vaginal delivery without complicating diagnoses
376 Postpartum and postabortion diagnoses without OR procedure
378 Ectopic pregnancy
379 Threatened abortion
380 Abortion without D and C
382 False labor
383 Other antepartum diagnoses with medical complications
384 Other antepartum diagnoses without medical complications
395 Red blood cell disorders, age greater than 17
396 Red blood cell disorders, age 0-17
397 Coagulation disorders
398 Reticuloendothelial and immunity disorders with CC
399 Reticuloendothelial and immunity disorders without CC
403 Lymphoma and nonacute leukemia with CC

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404 Lymphoma and nonacute leukemia without CC
405 Acute leukemia without major OR procedure, age 0-17
409 Radiotherapy
410 Chemotherapy without acute leukemia as secondary diagnosis
411 History of malignancy without endoscopy
412 History of malignancy with endoscopy
413 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses with CC
414 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses without CC
416 Septicemia, age greater than 17
417 Septicemia, age 0-17
418 Postoperative and posttraumatic infections
419 Fever of unknown origin, age greater than 17 with CC
420 Fever of unknown origin, age greater than 17 without CC
421 Viral illness, age greater than 17
422 Viral illness and fever of unknown origin, age 0-17
423 Other infectious and parasitic diseases diagnoses
425 Acute adjustment reactions and disturbances of psychosocial dysfunction
426 Depressive neuroses
427 Neuroses except depressive
428 Disorders of personality and impulse control
429 Organic disturbances and mental retardation
430 Psychoses
431 Childhood mental disorders
432 Other mental disorder diagnoses
433 Alcohol/drug abuse or dependence, left against medical advice
434 Alcohol/drug abuse or dependence, detoxification or other symptomatic treatment with CC
435 Alcohol/drug abuse or dependence, detoxification or other symptomatic treatment without CC
436 Alcohol/drug dependence with rehabilitation therapy
437 Alcohol/drug dependence with combined rehabilitation and detoxification therapy
444 Traumatic injury, age greater than 17 with CC
445 Traumatic injury, age greater than 17 without CC
446 Traumatic injury, age 0-17
447 Allergic reactions, age greater than 17
448 Allergic reactions, age 0-17
449 Poisoning and toxic effects of drugs, age greater than 17 with CC
450 Poisoning and toxic effects of drugs, age greater than 17 without CC
451 Poisoning and toxic effects of drugs, age 0-17
452 Complications of treatment with CC
453 Complications of treatment without CC
454 Other injury, poisoning and toxic effect diagnoses with CC
455 Other injury, poisoning and toxic effect diagnoses without CC
456 No longer valid
457 No longer valid
460 No longer valid
462 Rehabilitation
463 Signs and symptoms with CC
464 Signs and symptoms without CC
465 Aftercare with history of malignancy as secondary diagnosis
466 Aftercare without history of malignancy as secondary diagnosis
467 Other factors influencing health status
473 Acute leukemia without major OR procedure, age greater than 17
474 No longer valid
475 Respiratory system diagnosis with ventilator support
487 Other multiple significant trauma
489 HIV with major related condition
490 HIV with or without other related condition
492 Chemotherapy with acute leukemia as secondary diagnosis
505 Extensive 3rd degree burns without skin graft
508 Full thickness burn without skin graft or inhalation injury with CC or significant trauma
509 Full thickness burn without skin graft or inhalation injury without CC or significant trauma
510 Non-extensive burns with CC or significant trauma
511 Non-extensive burns without CC or significant trauma

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521 Alcohol/drug abuse or dependence with CC
522 Alcohol/drug abuse or dependence with rehabilitation therapy without CC
523 Alcohol/drug abuse or depend without rehabilitation therapy without CC
524 Transient ischemia

Include only patients with a length of stay of 5 or more days.

Exclude:
Patients in MDC 9(Skin, Subcutaneous Tissue, and Breast) or patients with any diagnosis of
hemiplegia, paraplegia, or quadriplegia. Obstetrical patients in MDC 14 (Pregnancy, Childbirth
and the Puerperium)
Patients admitted from a long-term care facility.

Hemiplegia, Paraplegia, or Quadriplegia

ICD-9-CM diagnosis codes (includes 4th and 5th digits):

3420 Flaccid hemiplegia

3421 Spastic hemiplegia
3428 Other specified hemiplegia
3429 Hemiplegia, unspecified
3430 Infantile cerebral palsy, diplegic
3431 Infantile cerebral palsy, hemiplegic
3432 Infantile cerebral palsy, quadriplegic
3433 Infantile cerebral palsy, monoplegic
3434 Infantile cerebral palsy infantile hemiplegia
3438 Infantile cerebral palsy other specified infantile cerebral palsy
3439 Infantile cerebral palsy, infantile cerebral palsy, unspecified
3440 Quadriplegia and quadriparesis
3441 Paraplegia
3442 Diplegia of upper limbs
3443 Monoplegia of lower limb
3444 Monoplegia of upper limb
3445 Unspecified monoplegia
3446 Cauda equina syndrome
3448 Other specified paralytic syndromes
3449 Paralysis, unspecified
4382 Hemiplegia/hemiparesis
4383 Monoplegia of upper limb
4384 Monoplegia of lower limb
4385 Other paralytic syndrome

Long-Term Care Facility

Admission source is recorded as long-term care facility (ASource=3)

Failure to Rescue
Numerator:
All discharges with a disposition of deceased per 1,000 population at risk.
Denominator:
Discharges with potential complications of care listed in failure to rescue (FTR) definition (e.g.,
pneumonia, DVT/PE, sepsis, acute renal failure, shock/cardiac arrest, or GI hemorrhage/acute
ulcer). Exclusion criteria specific to each diagnosis.

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FTRAcute Renal Failure
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

Acute renal failure:

5845 With lesion of tubular necrosis
5846 With lesion of renal cortical necrosis
5847 With lesion of renal medullary necrosis
5848 With other specified pathological lesion
5849 Acute renal failure, unspecified
6393 Complications following abortion and ectopic and molar pregnancies, renal failure
66930 Acute renal failure following labor and delivery, unspecified as to episode of care or not applicable
66932 Acute renal failure following labor and delivery, delivered, with mention of postpartum complication
66934 Acute renal failure following labor and delivery, postpartum condition or complication

Exclude principal diagnosis of acute renal failure, abortion-related renal failure, acute myocardial
infarction, cardiac arrest, cardiac arrhythmia, hemorrhage, GI hemorrhage, shock, or trauma.

Acute Renal Failure

ICD-9-CM diagnosis codes (when principal diagnosis):

Acute renal failure:

5845 With lesion of tubular necrosis
5846 With lesion of renal cortical necrosis
5847 With lesion of renal medullary necrosis
5848 With other specified pathological lesion
5849 Acute renal failure, unspecified
6393 Complications following abortion and ectopic and molar pregnancies, renal failure
66930 Acute renal failure following labor and delivery, unspecified as to episode of care or not applicable
66932 Acute renal failure following labor and delivery, delivered, with mention of postpartum complication
66934 Acute renal failure following labor and delivery, postpartum condition or complication

Abortion-related Renal Failure

ICD-9-CM diagnosis codes (when principal diagnosis):

63430 Spontaneous abortion with renal failure - unspecified

63431 Spontaneous abortion with renal failure - incomplete
63432 Spontaneous abortion with renal failure - complete
63530 Legal abortion with renal failure - unspecified
63531 Legal abortion with renal failure - incomplete
63532 Legal abortion with renal failure - complete
63630 Illegal abortion with renal failure - unspecified
63631 Illegal abortion with renal failure - incomplete
63632 Illegal abortion with renal failure - complete
63730 Abortion NOS with renal failure - unspecified
63731 Abortion NOS with renal failure - incomplete
63732 Abortion NOS with renal failure - complete
6383 Attempted abortion with renal failure

Acute Myocardial Infarction

ICD-9-CM diagnosis codes (when principal diagnosis):

41000 AMI of anterolateral wall episode of care unspecified

41001 AMI of anterolateral wall initial episode of care
41010 AMI of other anterior wall episode of care unspecified
41011 AMI of other anterior wall initial episode of care
41020 AMI of inferolateral wall episode of care unspecified
41021 AMI of inferolateral wall initial episode of care
41030 AMI of inferoposterior wall episode of care unspecified
41031 AMI of inferoposterior wall initial episode of care

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41040 AMI of inferior wall episode of care unspecified
41041 AMI of inferior wall initial episode of care
41050 AMI of other lateral wall episode of care unspecified
41051 AMI of other lateral wall initial episode of care
41060 AMI true posterior wall infarction episode of care unspecified
41061 AMI true posterior wall infarction initial episode of care
41070 AMI subendocardial infarction episode of care unspecified
41071 AMI subendocardial infarction initial episode of care
41080 AMI of other specified sites episode of care unspecified
41081 AMI of other specified sites initial episode of care
41090 AMI unspecified site episode of care unspecified
41091 AMI unspecified site initial episode of care

Cardiac Arrhythmia
ICD-9-CM diagnosis codes (when principal diagnosis):

4260 Atrioventricular block, complete

4270 Paroxysmal supraventricular tachycardia
4271 Paroxysmal ventricular tachycardia
4272 Paroxysmal tachycardia, unspecified
42731 Atrial fibrillation
42732 Atrial flutter
42741 Ventricular fibrillation
42742 Ventricular flutter
4279 Cardiac dysrhythmia

Cardiac Arrest
ICD-9-CM diagnosis code (when principal diagnosis):

4275 Cardiac arrest

Hemorrhage:
ICD-9-CM diagnosis codes (when principal diagnosis):

2851 Acute posthemorrhagic anemia

4590 Other disorders of circulatory system, hemorrhage, unspecified
9582 Certain early complications of trauma, secondary and recurrent hemorrhage
99811 Hemorrhage complicating a procedure

Shock
ICD-9-CM diagnosis codes (when principal diagnosis):

63450 Spontaneous abortion with shock - unspecified

63451 Spontaneous abortion with shock - incomplete
63452 Spontaneous abortion with shock - complete
63550 Legal abortion with shock - unspecified
63551 Legal abortion with shock - incomplete
63552 Legal abortion with shock - complete
63650 Illegal abortion with shock - unspecified
63651 Illegal abortion with shock - incomplete
63652 Illegal abortion with shock - complete
63750 Abortion NOS with shock - unspecified
63751 Abortion NOS with shock - incomplete
63752 Abortion NOS with shock - complete
6385 Attempted abortion with shock
6395 Complications following abortion and ectopic and molar pregnancies, shock
66910 Shock during or following labor and delivery, unspecified as to episode of care or not applicable
66911 Shock during or following labor and delivery, delivered with or without mention of antepartum condition
66912 Shock during or following labor and delivery, delivered with mention of postpartum complication
66913 Shock during or following labor and delivery, antepartum condition or complication
66914 Shock during or following labor and delivery, postpartum condition or complication

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7855 Shock without mention of trauma
78550 Shock, unspecified
78551 Cardiogenic shock
78559 Shock without mention of trauma, other
9950 Other anaphylactic shock
9954 Shock due to anesthesia
9980 Postoperative shock
9994 Anaphylactic shock, due to serum

Gastrointestinal (GI) Hemorrhage

ICD-9-CM diagnosis codes (when principal diagnosis):

4560 Esophageal varices with bleeding

45620 Esophageal varices in diseases classified elsewhere with bleeding
5307 Gastroesophageal laceration hemorrhage syndrome
53082 Esophageal hemorrhage
53100 Gastric ulcer acute with hemorrhage without mention of obstruction
53101 Gastric ulcer acute with hemorrhage with obstruction
53120 Gastric ulcer acute with hemorrhage and perforation without mention of obstruction
53121 Gastric ulcer acute with hemorrhage and perforation with obstruction
53140 Gastric ulcer chronic or unspecified with hemorrhage without mention of obstruction
53141 Gastric ulcer chronic or unspecified with hemorrhage with obstruction
53160 Gastric ulcer chronic or unspecified with hemorrhage and perforation without mention of obstruction
53161 Gastric ulcer chronic or unspecified with hemorrhage and perforation with obstruction
53200 Duodenal ulcer acute with hemorrhage without mention of obstruction
53201 Duodenal ulcer acute with hemorrhage with obstruction
53220 Duodenal ulcer acute with hemorrhage and perforation without mention of obstruction
53221 Duodenal ulcer acute with hemorrhage and perforation with obstruction
53240 Duodenal ulcer chronic or unspecified with hemorrhage without mention of obstruction
53241 Duodenal ulcer chronic or unspecified with hemorrhage with obstruction
53260 Duodenal ulcer chronic or unspecified with hemorrhage and perforation without mention of obstruction
53261 Duodenal ulcer chronic or unspecified with hemorrhage and perforation with obstruction
53300 Peptic ulcer, site unspecified, acute with hemorrhage without mention of obstruction
53301 Peptic ulcer, site unspecified, acute with hemorrhage with obstruction
53320 Peptic ulcer, site unspecified, acute with hemorrhage and perforation without mention of obstruction
53321 Peptic ulcer, site unspecified, acute with hemorrhage and perforation with obstruction
53340 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage without mention of obstruction
53341 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage with obstruction
53360 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage and perforation without mention of
obstruction
53361 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage and perforation with obstruction
53400 Gastrojejunal ulcer, acute with hemorrhage without mention of obstruction
53401 Gastrojejunal ulcer, acute with hemorrhage with obstruction
53420 Gastrojejunal ulcer, acute with hemorrhage and perforation without mention of obstruction
53421 Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
53440 Gastrojejunal ulcer, chronic or unspecified with hemorrhage without mention of obstruction
53441 Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
53460 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without mention of obstruction
53461 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
53501 Gastritis and duodenitis, acute gastritis with hemorrhage
53511 Gastritis and duodenitis, atrophic gastritis with hemorrhage
53521 Gastritis and duodenitis, gastric mucosal hypertrophy, with hemorrhage
53531 Gastritis and duodenitis, alcoholic gastritis, with hemorrhage
53541 Gastritis and duodenitis, other specified gastritis with hemorrhage
53551 Gastritis and duodenitis, unspecified gastritis and gastroduodenitis with hemorrhage
53561 Gastritis and duodenitis, duodenitis with hemorrhage
53783 Other specified disorders of stomach and duodenum, angiodysplasia of stomach and duodenum with
hemorrhage
53784 Dieulafoy lesion (hemorrhagic) of stomach and duodenum
56202 Diverticulosis of small intestine with hemorrhage
56203 Diverticulitis of small intestine with hemorrhage
56212 Diverticulosis of colon with hemorrhage

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56213 Diverticulitis of colon with hemorrhage
5693 Hemorrhage of rectum and anus
56985 Angiodysplasia of intestine - with hemorrhage
56986 Dieulafoy lesion (hemorrhagic) of intestine
5780 Gastrointestinal hemorrhage, hematemesis
5781 Gastrointestinal hemorrhage, blood in stool
5789 Gastrointestinal hemorrhage, hemorrhage of gastrointestinal tract, unspecified

FTRDVT/PE
Include ICD-9-CM diagnosis codes:

4151 Pulmonary embolism and infarction

41511 Iatrogenic pulmonary embolism
41519 Other pulmonary embolism and infarction
45111 Phlebitis and thorbophlebitis femoral vein (deep) (superficial)
45119 Phlebitis and thorbophlebitis, other deep vessel of lower extremities
4512 Phlebitis and thorbophlebitis, lower extremities
45181 Phlebitis and thorbophlebitis, iliac vein
4519 Phlebitis and thorbophlebitis, unspecified site
4538 Other venous embolism and thrombosis of other specified veins
4539 Other venous embolism and thrombosis of unspecified site

Exclude principal diagnosis of pulmonary embolism or deep vein thrombosis, abortion related
and postpartum obstetric pulmonary embolism.

Abortion related and postpartum obstetric pulmonary embolism

ICD-9-CM diagnosis codes (when principal diagnosis):

63460 Spontaneous abortion with embolism - unspecified

63461 Spontaneous abortion with embolism - incomplete
63462 Spontaneous abortion with embolism - complete
63560 Legal abortion with embolism - unspecified
63561 Legal abortion with embolism - incomplete
63562 Legal abortion with embolism - complete
63660 Illegal abortion with embolism - unspecified
63661 Illegal abortion with embolism - incomplete
63662 Illegal abortion with embolism - complete
63760 Abortion NOS with embolism - unspecified
63761 Abortion NOS with embolism - incomplete
63762 Abortion NOS with embolism - complete
6386 Attempted abortion with embolism
6396 Postabortion embolism
67320 Obstetrical blood-clot embolism, unspecified as to episode of care or not applicable
67321 Obstetrical blood-clot embolism, delivered, with or without mention of antepartum condition
67322 Obstetrical blood-clot embolism, delivered, with mention of postpartum complication
67323 Obstetrical blood-clot embolism, antepartum condition or complication
67324 Obstetrical blood-clot embolism, postpartum condition or complication

FTRPneumonia
Include ICD-9-CM diagnosis codes:

4820 Pneumonia due to klebsiella pneumoniae

4821 Pneumonia due to pseudomonas
4822 Pneumonia due to hemophilus influenzae [h. influenzae]
48230 Pneumonia due to streptococcus streptococcus, unspecified
48231 Pneumonia due to streptococcus group A
48232 Pneumonia due to streptococcus group B
48239 Pneumonia due to streptococcus other streptococcus
48240 Pneumonia due to staphylococcus pneumonia due to staphylococcus, unspecified
48241 Pneumonia due to staphylococcus pneumonia due to staphyloccoccus aureus

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48249 Pneumonia due to staphylococcus other staphylococcus pneumonia
48281 Pneumonia due to other specified bacteria anaerobes
48282 Pneumonia due to other specified bacteria excherichia coli [e coli]
48283 Pneumonia due to other specified bacteria other gram-negative bacteria
48284 Pneumonia due to other specified bacteria legionnaires' disease
48289 Pneumonia due to other specified bacteria other specified bacteria
4829 Bacterial pneumonia unspecified
485 Bronchopneumonia, organism unspecified
486 Pneumonia, organism unspecified
5070 Due to inhalation of food or vomitus
514 Pulmonary congestion and hypostasis

Exclude principal diagnosis code for pneumonia or 997.3, any diagnosis code for viral pneumonia,
MDC 4, and any diagnosis of immunocompromised state.

Viral pneumonia
ICD-9-CM diagnosis codes (includes 4th and 5th digits) (when principal diagnosis):

480 Viral pneumonia

481 Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]
483 Pneumonia due to other specified organism
484 Pneumonia in infectious diseases classified elsewhere
485 Bronchopneumonia, organism unspecified
487 Influenza

Immunocompromised States
ICD-9-CM diagnosis codes (when principal diagnosis):

042 Human immunodeficiency virus disease

1363 Pneumocystosis
27900 Hypogammaglobulinemia NOS
27901 Selective IgA immunodeficiency
27902 Selective IgM immunodeficiency
27903 Other selective immunoglobulin deficiencies
27904 Congenital hypogammaglobulinemia
27905 Immunodeficiency with increased IgM
27906 Common variable immunodeficiency
27909 Humoral immunity deficiency NEC
27910 Iimmunodeficiency with predominent T-cell defect, NOS
27911 DiGeorges syndrome
27912 Wiskott-Aldrich syndrome
27913 Nezelofs syndrome
27919 Deficiency of cell-mediated immunity, NOS
2792 Combined immunity deficiency
2793 Unspecified immunity deficiency
2794 Autoimmune disease, not elsewhere classified
2798 Other specified disorders involving the immune mechanism
2799 Unspecified disorder of immune mechanism

Complications of transplanted organ:

9968 Complications of transplanted organ
99680 Transplanted organ, unspecified
99681 Kidney transplant
99682 Liver transplant
99683 Heart transplant
99684 Lung transplant
99685 Bone marrow transplant
99686 Pancreas transplant
99687 Intestine transplant
99689 Other specified organ transplant

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V420 Kidney replaced by transplant
V421 Heart replaced by transplant
V426 Lung replaced by transplant
V427 Liver replaced by transplant
V428 Other specified organ or tissue
V4281 Bone marrow replaced by transplant
V4282 Peripheral stem cells replaced by transplant
V4283 Pancreas replaced by transplant
V4284 Intestines replace by transplant
V4289 Other replaced by transplant

ICD-9-CM procedure codes:

335 Lung transplantation

3350 Lung transplantation, NOS
3351 Unilateral lung transplantation
3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
375 Heart transplantation
410 Operations on bone marow and spleen
4100 Bone marrow transplant, NOS
4101 Autologous bone marrow transplant without purging
4102 Allogenic bone marrow transplant with purging
4103 Allogenic bone marrow transplant without purging
4104 Autologous hematopoietic stem cell transplant without purging
4105 Allogeneic hematopoietic stem cell transplant without purging
4106 Cord blood stem cell transplant
4107 Autologous hematopoietic stem cell transplant with purging
4108 Allogeneic hematopoietic stem cell transplant with purging
4109 Autologous bone marrow transplant with purging
5051 Auxiliary liver transplant
5059 Liver transplant, NEC
5280 Pancreatic transplant, NOS
5281 Reimplantation of pancreatic tissue
5282 Homotranplant of pancreas
5283 Heterotransplant of pancreas
5285 Allotransplantation of cells of islets of Langerhans
5286 Transplantation of cells of islets of Langerhans, NOS
5569 Other kidney transplantation

MDC 4 Diseases and disorders of the respiratory system

FTRSepsis
Include ICD-9-CM diagnosis codes:

0380 Streptococcal septicemia

0381 Staphylococcal septicemia
03810 Staphylococcal septicemia, unspecified
03811 Staphylococcus aureau septicemia
03819 Other staphylococcal septicemia
03840 Septicemia due to gram negative organism, unspecified
0382 Pneumococcal septicemia [streptococcus pneumoniae septicemia]
0383 Septicemia due to anaerobes
03841 Septicemia due to other gram-negative organisms, Hemophilus influenze [h. influenzae]
03842 Septicemia due to other gram-negative organisms, Escherichia coli [e coli]
03843 Septicemia due to other gram-negative organisms, Pseudomonas
03844 Septicemia due to other gram-negative organisms, Serratia
03849 Septicemia due to other gram-negative organisms, Other
0388 Other specified septicemias
0389 Unspecified septicemia
7907 Bacteremia

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99591 Systemic inflammatory response syndrome due to infectious process without organ dysfunction
99592 Systemic inflammatory response syndrome due to infection process with organ dysfunction

Exclude any diagnosis of immunocompromised state and principal diagnosis of infection or

sepsis and patients with a length of stay 3 days or less124.

Immunocompromised States
ICD-9-CM diagnosis codes (when principal diagnosis):

042 Human immunodeficiency virus disease

1363 Pneumocystosis
27900 Hypogammaglobulinemia NOS
27901 Selective IgA immunodeficiency
27902 Selective IgM immunodeficiency
27903 Other selective immunoglobulin deficiencies
27904 Congenital hypogammaglobulinemia
27905 Immunodeficiency with increased IgM
27906 Common variable immunodeficiency
27909 Humoral immunity deficiency NEC
27910 Immunodeficiency with predominent T-cell defect, NOS
27911 DiGeorges syndrome
27912 Wiskott-Aldrich syndrome
27913 Nezelofs syndrome
27919 Deficiency of cell-mediated immunity, NOS
2792 Combined immunity deficiency
2793 Unspecified immunity deficiency
2794 Autoimmune disease, not elsewhere classified
2798 Other specified disorders involving the immune mechanism
2799 Unspecified disorder of immune mechanism

Complications of transplanted organ:

9968 Complications of transplanted organ
99680 Transplanted organ, unspecified
99681 Kidney transplant
99682 Liver transplant
99683 Heart transplant
99684 Lung transplant
99685 Bone marrow transplant
99686 Pancreas transplant
99687 Intestine transplant
99689 Other specified organ transplant

V420 Kidney replaced by transplant

V421 Heart replaced by transplant
V426 Lung replaced by transplant
V427 Liver replaced by transplant
V428 Other specified organ or tissue
V4281 Bone marrow replaced by transplant
V4282 Peripheral stem cells replaced by transplant
V4283 Pancreas replaced by transplant
V4284 Intestines replace by transplant
V4289 Other replaced by transplant

ICD-9-CM procedure codes:

335 Lung transplantation

3350 Lung transplantation, NOS
3351 Unilateral lung transplantation

124
Note: The length of stay exclusion criteria has been corrected in this version of the PSI Guide. The
first version noted length of stay of 4 or more days which was incorrect.
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3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
375 Heart transplantation
410 Operations on bone marow and spleen
4100 Bone marrow transplant, NOS
4101 Autologous bone marrow transplant without purging
4102 Allogenic bone marrow transplant with purging
4103 Allogenic bone marrow transplant without purging
4104 Autologous hematopoietic stem cell transplant without purging
4105 Allogeneic hematopoietic stem cell transplant without purging
4106 Cord blood stem cell transplant
4107 Autologous hematopoietic stem cell transplant with purging
4108 Allogeneic hematopoietic stem cell transplant with purging
4109 Autologous bone marrow transplant with purging
5051 Auxiliary liver transplant
5059 Liver transplant, NEC
5280 Pancreatic transplant, NOS
5281 Reimplantation of pancreatic tissue
5282 Homotranplant of pancreas
5283 Heterotransplant of pancreas
5285 Allotransplantation of cells of islets of Langerhans
5286 Transplantation of cells of islets of Langerhans, NOS
5569 Other kidney transplantation

Infection
ICD-9-CM diagnosis codes (when principal diagnosis):

5400 Acute appendicitis with generalized peritonitis

5401 Acute appendicitis with peritoneal abscess
5409 Acute appendicitis without mention of peritonitis
541 Appendicitis, unqualified
542 Other appendicitis
56201 Diverticulitis of small intestine (without mention of hemorrhage)
56203 Diverticulitis of small intestine with hemorrhage
56211 Diverticulitis of colon (without mention of hemorrhage)
56213 Diverticulitis of colon with hemorrhage
566 Abscess of anal and rectal regions
5670 Peritonitis in infectious diseases classified elsewhere
5671 Pneumococcal peritonitis
5672 Other suppurative peritonitis
5678 Other specified peritonitis
5679 Unspecified peritonitis
5695 Abscess of intestine
56961 Infection of colostomy or enterostomy
5720 Abscess of liver
5721 Portal pyemia
57400 Calculus of gallbladder with acute cholecystitis - without mention of obstruction
57401 Calculus of gallbladder with acute cholecystits - with obstruction
57430 Calculus of bile duct with acute cholecystitis without mention of obstruction
57431 Calculus of bile duct with acute cholecystitis - with obstruction
57460 Calculus of gallbladder and bile duct with acute cholecystitis - without mention of obstruction
57461 Calculus of gallbladder and bile duct with acute cholecystitis - with obstruction
57480 Calculus of gallbladder and bile duct with acute and chronic cholecystitis - without mention of obstruction
57481 Calculus of gallbladder and bile duct with acute and chronic cholecystitis - with obstruction
5750 Acute cholecystitis
5754 Perforation of gallbladder
5761 Cholangitis
5763 Perforation of bile duct

DRGs:

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020 Nervous system infection except viral meningitis
068 Otitis media and URI, age greater than 17 with CC
069 Otitis media and URI, age greater than 17 without CC
079 Respiratory infections and inflammations, age greater than 17 with CC
080 Respiratory infections and inflammations, age greater than 17 without CC
081 Respiratory infections and inflammations, age 0-17
089 Simple pneumonia and pleurisy, age greater than 17 with CC
090 Simple pneumonia and pleurisy, age greater than 17 without CC
126 Acute and subacute endocarditis
238 Osteomyelitis
242 Septic arthritis
277 Cellulitis, age greater than 17 with CC
278 Cellulitis, age greater than 17 without CC
279 Cellulitis, age 0-17
320 Kidney and urinary tract infections, age greater than 17 with CC
321 Kidney and urinary tract infections, age greater than 17 without CC
322 Kidney and urinary tract infections, age 0-17
368 Infections of female reproductive system
415 OR procedure for infectious and parasitic diseases
416 Septicemia, age greater than 17
417 Septicemia, age 0-17
423 Other infectious and parasitic diseases diagnoses

FTRShock or Cardiac Arrest

Include ICD-9-CM diagnosis codes:

4275 cardiac arrest

6395 complications following abortion and ectopic and molar pregnancies, shock

Shock during or following labor and delivery:

66910 Shock during or following labor and delivery unspecified as to episode of care or not applicable
66911 Shock during or following labor and delivery delivered, with or without mention of antepartum condition
66912 Shock during or following labor and delivery delivered, with mention of postpartum complication
66913 Shock during or following labor and delivery antepartum condition or complication
66914 Shock during or following labor and delivery postpartum condition or complication
7855 Shock NOS
78550 Shock, unspecified
78551 Cardiogenic shock
78559 Shock without mention of trauma- other
7991 Respiratory arrest
9950 Other anaphylactic shock
9954 Shock due to anesthesia
9980 Postoperative shock
9994 Anaphylactic shock due to serum

ICD-9-CM procedure codes:

9393 Nonmechanical methods of resuscitation

9960 Cardiopulmonary resuscitation, NOS
9963 Closed chest cardiac massage

Exclude MDC 4 and 5, principal diagnosis of shock or cardiac arrest, abortion-related shock,
hemorrhage, trauma, GI hemorrhage.

MDC 4 Diseases and disorders of the respiratory system

MDC 5 Diseases and disorders of the circulatory system

Abortion-related Shock
ICD-9-CM diagnosis codes (when principal diagnosis):

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63450 Spontaneous abortion with shock - unspecified
63451 Spontaneous abortion with shock - incomplete
63452 Spontaneous abortion with shock - complete
63550 Legal abortion with shock - unspecified
63551 Legal abortion with shock - incomplete
63552 Legal abortion with shock - complete
63650 Illegal abortion with shock - unspecified
63651 Illegal abortion with shock - incomplete
63652 Illegal abortion with shock - complete
63750 Abortion NOS with shock - unspecified
63751 Abortion NOS with shock - incomplete
63752 Abortion NOS with shock - complete
6385 Attempted abortion with shock

FTRGI Hemorrhage/Acute Ulcer

Include ICD-9-CM diagnosis codes:

4560 Esophageal varices with bleeding

54620 Esophageal varices in diseases classified elsewhere with bleeding

Gastric ulcer:
53130 Acute without mention of hemorrhage or perforation without mention of obstruction
53131 Acute without mention of hemorrhage or perforation with obstruction
53190 Unspecified as acute or chronic, without mention of hemorrhage or perforation without mention of
obstruction
53191 Unspecified as acute or chronic, without mention of hemorrhage or perforation with obstruction

Duodenal ulcer:
53230 Acute without mention of hemorrhage or perforation without mention of obstruction
53231 Acute without mention of hemorrhage or perforation with obstruction
53290 Unspecified as acute or chronic, without mention of hemorrhage or perforation without mention of
obstruction
53291 Unspecified as acute or chronic, without mention of hemorrhage or perforation with obstruction

Peptic ulcer:
53330 Site unspecified acute without mention of hemorrhage and perforation without mention of obstruction
53331 Site unspecified acute without mention of hemorrhage and perforation with obstruction
53390 Site unspecified as acute or chronic, without mention of hemorrhage or perforation without mention of
obstruction
53391 Unspecified as acute or chronic, without mention of hemorrhage or perforation with obstruction

Gastrojejunal ulcer:
53430 Acute without mention of hemorrhage or perforation without mention of obstruction
53431 Acute without mention of hemorrhage or perforation with obstruction
53190 Unspecified as acute or chronic, without mention of hemorrhage or perforation without mention of
obstruction
53491 Unspecified as acute or chronic, without mention of hemorrhage or perforation with obstruction
5307 Gastroesophageal laceration-hemorrhage syndrome
53082 Esophageal hemorrhage

Gastric ulcer:
53100 Acute with hemorrhage without mention of obstruction
53101 Acute with hemorrhage with obstruction
53110 Acute with perforation without mention of obstruction
53111 Acute with perforation with obstruction
53120 Acute with hemorrhage and perforation without mention of obstruction
53121 Acute with hemorrhage and perforation with obstruction
53130 Acute without mention of hemorrhage or perforation without mention of obstruction

Duodenal ulcer:

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53200 Acute with hemorrhage without mention of obstruction
53201 Acute with hemorrhage with obstruction
53210 Acute with perforation without mention of obstruction
53211 Acute with perforation with obstruction
53220 Acute with hemorrhage and perforation without mention of obstruction
53221 Acute with hemorrhage and perforation with obstruction

Peptic ulcer:
53300 Site unspecified acute with hemorrhage without mention of obstruction
53301 Site unspecified acute with hemorrhage with obstruction
53310 Site unspecified acute with perforation without mention of obstruction
53311 Site unspecified acute with perforation with obstruction
53320 Site unspecified acute with hemorrhage and perforation without mention of obstruction
53321 Site unspecified acute with hemorrhage and perforation without mention of obstruction

Gastrojejunal ulcer:
53400 Acute with hemorrhage without mention of obstruction
53401 Acute with hemorrhage with obstruction
53410 Acute with perforation without mention of obstruction
53411 Acute with perforation with obstruction
53420 Acute with hemorrhage and perforation without mention of obstruction
53421 Acute with hemorrhage and perforation with obstruction
53430 Acute without mention of hemorrhage or perforation - without mention of obstruction

Gastritis and duodenitis:

53501 Acute gastritis with hemorrhage
53511 Atrophic gastritis with hemorrhage
53521 Gastric mucosal hypertrophy with hemorrhage
53531 Alcoholic gastritis with hemorrhage
53541 Other specified gastritis with hemorrhage
53551 Unspecified gastritis and gastroduodenitis with hemorrhage
53561 Duodenitis with hemorrhage
53783 Angiodysplasia of stomach and duodenum with hemorrhage
53784 Dieulafoy lesion (hemorrhagic) of stomach and duodenum
56202 Diverticulosis of small intestine with hemorrhage
56203 Diverticulitis of small intestine with hemorrhage
56212 Diverticulosis of colon with hemorrhage
56213 Diverticulitis of colon with hemorrhage
5693 Hemorrhage of rectum and anus
56985 Angiodysplasia of intestine with hemorrhage
56986 Dieulafoy lesion (hemorrhagic) of intestine
5780 Hematemesis
5781 Blood in stool
5789 Hemorrhage of gastrointestinal tract, unspecified

Exclude MDC codes and ICD-9-CM diagnosis codes:

MDC 6 Diseases and disorders of the digestive system

MDC 7 Diseases and disorders of the hepatobiliary system and pancreas

2800 Secondary to blood loss [chronic]

2851 Acute posthemorrhagic anemia

Exclude principal diagnosis of FTR-GI hemorrhage, trauma, and alcoholism.

Alcoholism
ICD-9-CM diagnosis codes (when principal diagnosis):

2910 Alcohol withdrawal delirium

2911 Alcohol amnestic syndrome

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2912 Other alcoholic dementia
2913 Alcohol withdrawal hallucinosis
2914 Idiosyncratic alcohol intoxication
2915 Alcoholic jealousy
29181 Other specified alcoholic psychoses, alcohol withdrawal
29189 Other specified alcoholic psychoses, other
2919 Unspecified alcoholic psychosis
30300 Acute alcoholic intoxication - unspecified
30301 Acute alcoholic intoxication - continuous
30302 Acute alcoholic intoxication - episodic
30303 Acute alcoholic intoxication - in remission
30390 Other and unspecified alcohol dependence - unspecified
30391 Other and unspecified alcohol dependence - continuous
30392 Other and unspecified alcohol dependence - episodic
30393 Other and unspecified alcohol dependence - in remission
30500 Nondependent abuse of drugs, alcohol abuse - unspecified
30501 Nondependent abuse of drugs, alcohol abuse - continuous
30502 Nondependent abuse of drugs, alcohol abuse - episodic
30503 Nondependent abuse of drugs, alcohol abuse in remission
4255 Alcoholic cardiomyopathy
53530 Alcoholic gastritis, without mention of hemorrhage
53531 Alcoholic gastritis, with hemorrhage
5710 Alcoholic fatty liver
5711 Acute alcoholic hepatitis
5712 Alcoholic cirrhosis of liver
5713 Alcoholic liver damage, unspecified
9800 Toxic effect of alcohol, ethyl alcohol
9809 Toxic effect of alcohol, unspecified alcohol
Exclude:
Patients age 75 years and older.
Neonatal patients in MDC 15 (Newborns and Other Neonates with Conditions Originating in the
Neonatal Period).
Patients transferred to an acute care facility
Patients transferred from an acute care facility
Patients admitted from a long-term care facility

Transferred to Acute Care Facility

Discharge disposition recorded as transfer to another acute care facility (Discharge Disposition = 2)

Transferred from Acute Care or Long-Term Care Facility

Admission source is recorded as acute care facility (Admission Source = 2)

Admission source is recorded as long-term care facility (Admission Source=3)

Foreign Body Left During Procedure

Numerator:
Discharges with ICD-9-CM codes for foreign body left in during procedure in any secondary
diagnosis field per 1,000 surgical discharges.

Foreign Body Left in During Procedure

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Foreign Body Left During Procedure
ICD-9-CM diagnosis codes:

9984 Foreign body accidentally left during a procedure

9987 Acute reactions to foreign substance accidentally left during a procedure

Foreign body left in during:

E8710 Surgical operation
E8711 Infusion or transfusion
E8712 Kidney dialysis or other perfusion
E8713 Injection or vaccination
E8714 Endoscopic examination
E8715 Aspiration of fluid or tissue, puncture, and catheterization
E8716 Heart catheterization
E8717 Removal of catheter or packing
E8718 Other specified procedures
E8719 Unspecified procedure

Denominator:
All medical and surgical discharges defined by specific DRGs (see denominators for Decubitus
Ulcer for medical discharges and Complications of Anesthesia for surgical discharges).

Iatrogenic Pneumothorax
Numerator:
Discharges with ICD-9-CM code of 5121 in any secondary diagnosis field per 1,000 discharges.
Denominator:
All medical and surgical discharges defined by specific DRGs (see denominators for Decubitus
Ulcer for medical discharges and Complications of Anesthesia for surgical discharges).
Exclude:
Patients with any diagnosis of trauma.
Patients with any code indicating thoracic surgery, lung or pleural biopsy, or cardiac surgery.
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).

Trauma
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

800 Fracture of vault of skull

801 Fracture of base of skull
802 Fracture of face bones
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones
805 Fracture of vertebral column without mention of spinal cord injury
806 Fracture of vertebral column with spinal cord injury
807 Fracture of rib[s] sternum, larynx, and trachea
808 Fracture of pelvis
809 Ill-defined fractures of bones of trunk
810 Fracture of clavicle
811 Fracture of scapula
812 Fracture of humerous
813 Fracture of radius and ulna
814 Fracture of carpal bone[s]
815 Fracture of metacarpal bone[s]
817 Multiple fracture of hand bones

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818 Ill-defined fractures of upper limb
819 Multiple fractures involving both upper limbs, and upper limb with rib and sternum
820 Fracture of neck of femur
821 Fracture of other and unspecified parts of femur
822 Fracture of patella
823 Fracture of tibia and fibula
824 Fracture of ankle
825 Fracture of one or more tarsal and metatarsal bones
827 Other, multiple, and ill-defined fractures of lower limb
828 Multiple fractures involving both lower limbs, lower with upper limb, and lower limb with rib and sternum
829 Fracture of unspecified bones
830 Dislocation of jaw
831 Dislocation of shoulder
832 Dislocation of elbow
833 Dislocation of wrist
835 Dislocation of hip
836 Dislocation of knee
837 Dislocation of ankle
838 Dislocation of foot
839 Other, multiple, and ill-defined dislocations
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following injury
853 Other and unspecified intracranial hemorrhage following injury
854 Intracranial injury of other and unspecified nature
860 Traumatic pneumothorax
861 Injury to heart and lung
862 Injury to other and unspecified intrathoracic organs
863 Injury to gastrointestinal tract
864 Injury to liver
865 Injury to spleen
866 Injury to kidney
867 Injury to pelvic organs
868 Injury to other intra-abdominal organs
869 Internal injury to unspecified or ill-defined organs
870 Open wound of ocular adnexa
871 Open wound of eyeball
872 Open wound of ear
873 Other open wound of head
874 Open wound of neck
875 Open wound of chest [wall]
876 Open wound of back
877 Open wound of buttock
878 Open wound of genital organs [external] including traumatic amputation
879 Open wound of other and unspecified sites, except limbs
880 Open wound of shoulder and upper arm
881 Open wound of elbow, forearm, and wrist
882 Open wound of hand except finger alone
884 Multiple and unspecified open wound of upper limb
887 Traumatic amputation of arm and hand (complete) (partial)
890 Open wound of hip and thigh
891 Open wound of knee, leg (except thigh) and ankle
892 Open wound of foot except toe alone
894 Multiple and unspecified open wound of lower limb
896 Traumatic amputation of foot (complete) (partial)
897 Traumatic amputation of leg[s] (complete) (partial)
900 Injury to blood vessels of head and neck
901 Injury to blood vessels of thorax
902 Injury to blood vessels of abdomen and pelvis
903 Injury to blood vessels of upper extremity
904 Injury to blood vessels of lower extremity and unspecified sites
925 Crushing injury of face, scalp, and neck

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Iatrogenic Pneumothorax
926 Crushing injury of trunk
927 Crushing injury of upper limb
928 Crushing injury of lower limb
929 Crushing injury of multiple and unspecified sites
940 Burn confined to eye and adnexa
941 Burn of face, head, and neck
942 Burn of trunk
943 Burn of upper limb, except wrist and hand
944 Burn of wrist[s] and hand[s]
945 Burn of lower limb[s]
946 Burns of multiple specified sites
947 Burn of internal organs
948 Burns classified according to extent of body surface involved
949 Burn, unspecified
952 Spinal chord injury without evidence of spinal bone injury
953 Injury to nerve roots and spinal plexus
958 Certain early complications of trauma

DRGs:

002 Craniotomy for trauma, age greater than 17

027 Traumatic stupor and coma, coma greater than one hour
028 Traumatic stupor and coma, coma less than one hour, age greater than 17 with CC
029 Traumatic stupor and coma, coma less than one hour, age greater than 17 without CC
030 Traumatic stupor and coma, coma less than one hour, age 0-17
031 Concussion, age greater than 17 with CC
032 Concussion, age greater than 17 without CC
033 Concussion, age 0-17
072 Nasal trauma and deformity
083 Major chest trauma with CC
084 Major chest trauma without CC
235 Fractures of femur
236 Fracture of hip and pelvis
237 Sprains, strains and dislocations of hip, pelvis and thigh
440 Wound debridements for injuries
441 Hand procedures for injuries
442 Other OR procedures for injuries with CC
443 Other OR procedures for injuries without CC
444 Traumatic injury, age greater than 17 with CC
445 Traumatic injury, age greater than 17 without CC
446 Traumatic injury, age 0-17
456 No longer valid
457 No longer valid
458 No longer valid
459 No longer valid
460 No longer valid
484 Craniotomy for multiple significant trauma
485 Limb reattachment, hip and femur procedures for multiple significant trauma
486 Other OR procedures for multiple significant trauma
487 Other multiple significant traumas
491 Major joint and limb reattachment procedures of upper extremity
504 Total hepatectomy
505 Extensive 3rd degree burns w/o skin graft
506 Full thickness burn with skin graft or inhalation injury with CC or significant trauma
507 Full thickness burn with skin graft or inhalation injury without CC or significant trauma
508 Full thickness burn without skin graft or inhalation injury with CC or significant trauma
509 Full thickness burn without skin graft or inhalation injury without CC or significant trauma
510 Non-extensive burns with CC or significant trauma
511 Non-extensive burns without CC or significant trauma

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Iatrogenic Pneumothorax
Thoracic Surgery
ICD-9-CM procedure codes:

3121 Mediastinal tracheostomy

3145 Open biopsy of larynx or trachea
3173 Closure of other fistula of trachea
3179 Other repair and plastic operations on trachea
3199 Other operations on trachea
3209 Other local excision or destruction of lesion or tissue of bronchus
321 Other excision of bronchus

Local excision or destruction of lesion or tissue of lung:

3221 Plication of emphysematious bleb
3222 Lung volume reduction surgery
3228 Endoscopic excision or destruction of lesion or tissue of lung
3229 Other local excision or destruction of lesion or tissue of lung
323 Segmental resection of lung
324 Lobectomy of lung
325 Complete pneumonectomy
326 Radical dissection of thoracic structures
329 Other excision of lung
330 Incision of bronchus
331 Incision of lung
3325 Open biopsy of bronchus
3326 Close [percutaneous][needle] biopsy of lung
3327 Closed endoscopic biopsy of lung
3328 Open biopsy of lung
3331 Destruction of phrenic nerve for collapse of lung (no longer performed)
3332 Artificial pneumothorax for collapse of lung
3334 Thoracoplasty
3339 Other surgical collapse of lung

Repair and plastic operation on lung and bronchus:

3341 Suture of laceration of bronchus
3342 Closure of bronchial fistula
3343 Closure of laceration of lung
3348 Other repair and plastic operations on bronchus
3349 Other repair and plastic operations on lung

Lung transplant:
3350 Lung transplantation, NOS
3351 Unilateral lung transplantation
3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
3392 Ligation of bronchus
3393 Puncture of lung
3398 Other operations on bronchus
3399 Other operations on lung
3329 Other diagnostic procedure on lung and bronchus
3333 Pneumoperitoneum for collapse of lung
3401 Incision of chest wall
3402 Exploratory thoracotomy
3403 Reopening of recent thoracotomy site
3405 Creation of pleuroperitoneal shunt
3409 Other incision of pleura
341 Incision of mediastinum

Diagnostic procedures on chest wall, pleura, mediastinum, and diaphragm:

3421 Transpleural thoracosocopy
3422 Mediastinoscopy

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Iatrogenic Pneumothorax
3423 Biopsy of chest wall
3424 Pleural biopsy
3425 Closed [percutaneous][needle] biopsy of mediastinum
3426 Open biopsy of mediastinum
3427 Biopsy of diaphragm
3428 Other diagnostic procedures on chest wall, pleura, and diaphragm
3429 Other diagnostic procedures on mediastinum
343 Excision or destruction of lesion or tissue of mediastinum
344 Excision or destruction of lesion of chest wall
3451 Decortication of lung
3459 Other excision of pleura

Repair of chest wall:

3471 Suture of laceration of chest wall
3472 Closure of thoracostomy
3473 Closure of other fistula of thorax
3474 Repair of pectus deformity
3479 Other repair of chest wall

Operations on diaphragm:
3481 Excision of lesion or tissue of diaphragm
3482 Suture of laceration of diaphragm
3483 Closure of fistula of diaphragm
3484 Other repair of diaphragm
3485 Implantation of diaphragmatic pacemaker
3489 Other operations on diaphragm
3493 Repair of pleura
3499 Other operations on thorax, other

Operations on thoracic duct:

4061 Cannulation of thoracic duct
4062 Fistulization of thoracic duct
4063 Closure of fistula of thoracic duct
4064 Ligation of thoracic duct
4069 Other operations on thoracic duct

Esophagotomy:
4201 Incision of esophageal web
4209 Other incision of esophagus
4210 Esophagostomy, NOS
4211 Cervical esophagostomy
4212 Exteriorization of esophageal pouch
4219 Other external fistulization of esophagus
4221 Operative esophagoscopy by incision
4225 Open biopsy of esophagus
4231 Local excision of esophageal diverticulum
4232 Local excision of other lesion or tissue of esophagus
4239 Other destruction of lesion or tissue of esophagus

Excision of esophagus:
4240 Esophagectomy, NOS
4241 Partial esophagectomy
4242 Total esophagectomy

Intrathoracic anastomosis of exophagus

4251 Intrathoracic esophagoesophagostomy
4252 Intrathoracic esophagogastrostomy
4253 Intrathoracic esophageal anastomosis with interposition of small bowel
4254 Other intrathoracic esophagoenterostomy
4255 Intrathoracic esophageal anastomosis with interposition of colon
4256 Other intrathoracic esophagocolostomy

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Iatrogenic Pneumothorax
4258 Intrathoracic esophageal anastomosis with other interposition
4259 Other intrathoracic anastomosis of esophagus

Antesternal anastomosis
4261 Antesternal esophagoesophagostomy
4262 Antesternal esophagogastrostomy
4263 Antesternal esophageal anastomosis with interposition of small bowel
4264 Other antesternal esophagoenterostomy
4265 Antesternal esophageal anastomosis with interposition of colon
4266 Other antesternal esophagocolostomy
4268 Other antesternal esophageal anastomosis with interposition
4269 Other antesternal anastomosis of esophagus
427 Esophagomyotomy

Other repair of esophagus

4281 Insertion of permanent tube into esophagus
4282 Suture of laceration of esophagus
4283 Closure of esophagostomy
4284 Repair of esophageal fistula, NEC
4285 Repair of esophageal stricture
4286 Production of subcutaneous tunnel without esophageal anastomosis
4287 Other graft of esophagus
4289 Other repair of esophagus
4465 Esophagogastroplasty
4466 Other procedures for creation of esophagogastric sphincteric competence
8104 Dorsal and dorso-lumbar fusion, anterior technique
8134 Refusion of dorsal and dorsolumbar spine, anterior technique

Lung or Pleural Biopsy

ICD-9-CM procedure codes:

3326 Closed [percutaneous] [needle] biopsy of lung

3328 Open biopsy of lung
3424 Pleural biopsy

Cardiac Surgery
DRGs:

103 Heart transplant

104 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization
105 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization
106 Coronary bypass with PTCA
107 Coronary bypass with cardiac catheterization
108 Other cardiothoracic procedures
109 Coronary bypass without cardiac catheterization
110 Major cardiovascular procedures with CC
111 Major cardiovascular procedures without CC

Selected Infections Due to Medical Care

Numerator:
Discharges with ICD-9-CM code of 9993 or 99662 in any secondary diagnosis field per 1,000
discharges.
Denominator:
All medical and surgical discharges defined by specific DRGs (see denominators for Decubitus
Ulcer for medical discharges and Complications of Anesthesia for surgical discharges).

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Selected Infections Due to Medical Care
Exclude:
Patients with any code for immunocompromised state or cancer.

Immunocompromised States
ICD-9-CM diagnosis codes:

042 Human immunodeficiency virus disease

1363 Pneumocystosis
27900 Hypogammaglobulinemia NOS
27901 Selective IgA immunodeficiency
27902 Selective IgM immunodeficiency
27903 Other selective immunoglobulin deficiencies
27904 Congenital hypogammaglobulinemia
27905 Immunodeficiency with increased IgM
27906 Common variable immunodeficiency
27909 Humoral immunity deficiency NEC
27910 Immunodeficiency with predominent T-cell defect, NOS
27911 DiGeorges syndrome
27912 Wiskott-Aldrich syndrome
27913 Nezelofs syndrome
27919 Deficiency of cell-mediated immunity, NOS
2792 Combined immunity deficiency
2793 Unspecified immunity deficiency
2794 Autoimmune disease, not elsewhere classified
2798 Other specified disorders involving the immune mechanism
2799 Unspecified disorder of immune mechanism

Complications of transplanted organ:

9968 Complications of transplanted organ
99680 Transplanted organ, unspecified
99681 Kidney transplant
99682 Liver transplant
99683 Heart transplant
99684 Lung transplant
99685 Bone marrow transplant
99686 Pancreas transplant
99687 Intestine transplant
99689 Other specified organ transplant

V420 Kidney replaced by transplant

V421 Heart replaced by transplant
V426 Lung replaced by transplant
V427 Liver replaced by transplant
V428 Other specified organ or tissue
V4281 Bone marrow replaced by transplant
V4282 Peripheral stem cells replaced by transplant
V4283 Pancreas replaced by transplant
V4284 Intestines replace by transplant
V4289 Other replaced by transplant

ICD-9-CM procedure codes:

335 Lung transplantation

3350 Lung transplantation, NOS
3351 Unilateral lung transplantation
3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
375 Heart transplantation
410 Operations on bone marow and spleen
4100 Bone marrow transplant, NOS

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Selected Infections Due to Medical Care
4101 Autologous bone marrow transplant without purging
4102 Allogenic bone marrow transplant with purging
4103 Allogenic bone marrow transplant without purging
4104 Autologous hematopoietic stem cell transplant without purging
4105 Allogeneic hematopoietic stem cell transplant without purging
4106 Cord blood stem cell transplant
4107 Autologous hematopoietic stem cell transplant with purging
4108 Allogeneic hematopoietic stem cell transplant with purging
4109 Autologous bone marrow transplant with purging
5051 Auxiliary liver transplant
5059 Liver transplant, NEC
5280 Pancreatic transplant, NOS
5281 Reimplantation of pancreatic tissue
5282 Homotranplant of pancreas
5283 Heterotransplant of pancreas
5285 Allotransplantation of cells of islets of Langerhans
5286 Transplantation of cells of islets of Langerhans, NOS
5569 Other kidney transplantation

Cancer
ICD-9-CM diagnosis codes (include 4th and 5th digits):

140 Malignant neoplasm of lip

141 Malignant neoplasm of tongue
142 Malignant neoplasm of major salivary glands
143 Malignant neoplasm of gum
144 Malignant neoplasm of floor of mouth
145 Malignant neoplasm of other and unspecified parts of mouth
146 Malignant neoplasm of oropharynx
147 Malignant neoplasm of nasopharynx
148 Malignant neoplasm of hypopharynx
149 Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
150 Malignant neoplasm of esophagus
151 Malignant neoplasm of stomach
152 Malignant neoplasm of small intestine, including duodenum
153 Malignant neoplasm of colon
154 Malignant neoplasm of rectum, rectosigmoid junction, and anus
155 Malignant neoplasm of liver and intrahepatic bile ducts
156 Malignant neoplasm of gallbladder and extrahepatic bile ducts
157 Malignant neoplasm of pancreas
158 Malignant neoplasm of retroperitoneum and peritoneum
159 Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
160 Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
161 Malignant neoplasm of larynx
162 Malignant neoplasm of trachea, bronchus, and lung
163 Malignant neoplasm of pleura
164 Malignant neoplasm of thymus, heart, and mediastinum
165 Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170 Malignant neoplasm of bone and articular cartilage
171 Malignant neoplasm of connective and other soft tissue
172 Malignant melanoma of skin
174 Malignant neoplasm of female breast
175 Malignant neoplasm of male breast
176 Karposis sarcoma
179 Malignant neoplasm of uterus, part unspecified
180 Malignant neoplasm of cervix uteri
181 Malignant neoplasm of eye
182 Malignant neoplasm of body of uterus
183 Malignant neoplasm of ovary and other uterine adnexa
184 Malignant neoplasm of other and unspecified female genital organs
185 Malignant neoplasm of other and unspecified female genital organs
186 Malignant neoplasm of testes

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Selected Infections Due to Medical Care
187 Malignant neoplasm of penis and other male genital organs
188 Malignant neoplasm of bladder
189 Malignant neoplasm of kidney and other and unspecified urinary organs
190 Malignant neoplasm of eye
191 Malignant neoplasm of brain
192 Malignant neoplasm of other and unspecified parts of nervous system
193 Malignant neoplasm of thyroid gland
194 Malignant neoplasm of other endocrine glands and related structures
195 Malignant neoplasm of other, and ill-defined sites
196 Secondary and unspecified malignant neoplasm of lymph nodes
197 Secondary malignant neoplasm of respiratory and digestive systems
198 Secondary malignant neoplasm of other specified sites
199 Malignant neoplasm without specification of site
200 Lymphosarcoma and reticulosarcoma
201 Hodgkins disease
202 Other malignant neoplasms of lymphoid and histiocytic tissues
203 Multiple myeloma and immunoproliferative neoplasms
204 Lymphoid leukemia
205 Myeloid leukemia
206 Monocytic leukemia
207 Other specified leukemia
208 Leukemia of unspecified cell type
2386 Neoplasm of uncertain behavior of other and unspecified sites and tissues, plasma cells
2733 Macroglobulinemia

Personal history of malignant neoplasm:

V1000 Gastrointestinal tract, unspecified
V1001 Tongue
V1002 Other and unspecified oral cavity and pharynx
V1003 Esophagus
V1004 Stomach
V1005 Large intestine
V1006 Rectum, rectosigmoid junction, and anus
V1007 Liver
V1009 Other
V1011 Bronchus and lung
V1012 Trachea
V1020 Respiratory organ, unspecified
V1021 Larynx
V1022 Nasal cavities, middle ear, and accessory sinuses
V1029 Other respiratory and intrathoracic organs, other
V103 Breast
V1040 Female genital organ, unspecified
V1041 Cervix uteri
V1042 Other parts of uterus
V1043 Ovary
V1044 Other female genital organs
V1045 Male genital organ, unspecified
V1046 Prostate
V1047 Testes
V1048 Epiddidymis
V1049 Other male genital organs
V1050 Urinary organ, unspecified
V1051 Bladder
V1052 Kidney
V1053 Renal pelvis
V1059 Urinary organs, other
V1060 Leukemia, unspecified
V1061 Lymphid leukemia
V1062 Myeloid leukemia
V1063 Monocytic leukemia
V1069 Leukemia, other

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Selected Infections Due to Medical Care
V1071 Lymphosarcoma and reticulosarcoma
V1072 Hodgkins disease
V1079 Other lymphatic and hematopoietic neoplasms, other
V1081 Bone
V1082 Malignant melanoma of skin
V1083 Other malignant neoplasm of skin
V1084 Eye
V1085 Brain
V1086 Other parts of nervous system
V1087 Thyroid
V1088 Other endocrine glands and related structures
V1089 Other
V109 Unspecified personal history of malignant neoplasm

DRGs:

010 Nervous system neoplasms with CC

011 Nervous system neoplasms without CC
064 Ear, nose, mouth and throat malignancy
082 Respiratory neoplasms
172 Digestive malignancy with CC
173 Digestive malignancy without CC
199 Hepatobiliary diagnostic procedure for malignancy
203 Malignancy of hepatobiliary system or pancreas
239 Pathological fractures and musculoskeletal and connective tissue malignancy
257 Total mastectomy for malignancy with CC
258 Total mastectomy for malignancy without CC
259 Subtotal mastectomy for malignancy with CC
260 Subtotal mastectomy for malignancy without CC
274 Malignant breast disorders with CC
275 Malignant breast disorders without CC
303 Kidney, ureter and major bladder procedures for neoplasm
318 Kidney and urinary tract neoplasms with CC
319 Kidney and urinary tract neoplasms without CC
338 Testes procedures for malignancy
344 Other male reproductive system OR procedures for malignancy
346 Malignancy of male reproductive system with CC
347 Malignancy of male reproductive system without CC
354 Uterine and adnexa procedures for nonovarian/adnexal malignancy with CC
355 Uterine and adnexa procedures for nonovarian/adnexal malignancy without CC
357 Uterine and adnexa procedures for ovarian or adnexal malignancy
363 D and C, conization and radioimplant for malignancy
367 Malignancy of female reproductive system without CC
400 Lymphoma and leukemia with major OR procedures
401 Lymphoma and nonacute leukemia with other OR procedure with CC
402 Lymphoma and nonacute leukemia with other OR procedure without CC
403 Lymphoma and nonacute leukemia with CC
404 Lymphoma and nonacute leukemia without CC
405 Acute leukemia without major or procedure, age 0-17
406 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedures with CC
407 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedure without CC
408 Myeloproliferative disorders or poorly differentiated neoplasms with other OR procedures
409 Radiotherapy
410 Chemotherapy without acute leukemia as secondary diagnosis
411 History of malignancy without endoscopy
412 History of malignancy with endoscopy
413 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses with CC
414 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses without CC
473 Acute leukemia without major OR procedure, age greater than 17
492 Chemotherapy with acute leukemia as secondary diagnosis

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Postoperative Hemorrhage or Hematoma
Numerator:
Discharges with ICD-9-CM codes for postoperative hemorrhage in any secondary diagnosis field
and postoperative control of hemorrhage in seconday procedure field or postoperative hematoma
in any secondary diagnosis field and code for or drainage of hematoma in any secondary
procedure code field per 1,000 surgical discharges.
Procedure code for postoperative control of hemorrhage or hematoma must occur on the same
day or after the principal procedure.

Postoperative Hematoma
ICD-9-CM diagnosis code:

99812 Hematoma complicating a procedure

Postoperative Hemorrhage
ICD-9-CM diagnosis code:

99811 Hemorrhage complicating a procedure

Control of Postoperative Hemorrhage

ICD-9-CM procedure codes:

287 Control of hemorrhage after tonsillectomy and adenoidectomy

3880 Other surgical occlusion of unspecified site
3881 Other surgical occlusion of intracranial vessels
3882 Other surgical occlusion of other vessels of head and neck
3883 Other surgical occlusion of upper limb vessels
3884 Other surgical occlusion of aorta, abdominal
3885 Other surgical occlusion of thoracic vessel
3886 Other surgical occlusion of abdominal arteries
3887 Other surgical occlusion of abdominal veins
3888 Other surgical occlusion of lower limb arteries
3889 Other surgical occlusion of lower limb veins
3941 Control of hemorrhage following vascular surgery
3998 Control of hemorrhage NOS
4995 Control of (postoperative) hemorrhage of anus
5793 Control of (postoperative hemorrhage of bladder
6094 Control of (postoperative) hemorrhage of prostate

Drainage of Hematoma
ICD-9-CM procedure codes:

1809 Other incision of external ear

540 Incision of abdominal wall
5412 Reopening of recent laparotomy site
5919 Other incision of perivesicle tissue
610 Incision and drainage of scrotum and tunica and vaginalis
6998 Other operations on supporting structures of uterus
7014 Other vaginotomy
7109 Other incision of vulva and perineum
7591 Evacuation of obstetrical incisional hematoma of perineum
7592 Evacuation of other hematoma of vulva or vagina
8604 Other incision with drainage of skin and subcutaneous tissue

Denominator:

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Postoperative Hemorrhage or Hematoma
All surgical discharges defined by specific DRGs (see denominator for Complications of
Anesthesia).
Exclude:
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).

Postoperative Hip Fracture

Numerator:
Discharges with ICD-9-CM code for hip fracture in any secondary diagnosis field per 1,000
surgical discharges.

Hip Fracture
ICD-9-CM diagnosis codes (includes all 5th digits):

8200 Fracture of neck of femur transcervical fracture, closed

8201 Fracture of neck of femur transcervical fracture, open
8202 Fracture of neck of femur pertrochanteric fracture, closed
8203 Fracture of neck of femur pertrochanteric fracture, open
8208 Unspecified part of neck of femur, closed
8209 Unspecified part of neck of femur, open

Denominator:
All surgical discharges defined by specific DRGs (see denominator for Complications of
Anesthesia).
Exclude:
Patients who have diseases and disorders of the musculoskeletal system and connective tissue
(MDC 8).
Patients with principal diagnosis codes for seizure, syncope, stroke, coma, cardiac arrest,
poisoning, trauma, delirium and other psychoses, or anoxic brain injury.
Patients with any diagnosis of metastatic cancer, lymphoid malignancy or bone malignancy, or
self-inflicted injury.
Obstetrical patients in MDC14 (Pregnancy, Childbirth and the Puerperium).
Patients 17 years of age and younger.

Seizure
ICD-9-CM diagnosis codes:

34500 Generalized nonconvulsive epilepsy without mention of intractable epilepsy

34501 Generalized nonconvulsive epilepsy with intractable epilepsy
34510 Generalized convulsive epilepsy without mention of intractable epilepsy
34511 Generalized convulsive epilepsy with intractable epilepsy
3452 Epilepsy Petit mal status
3453 Epilepsy Grand mal status
34540 Partial epilepsy, with impairment of consciousness with intractable epilepsy
34541 Partial epilepsy, with impairment of consciousness without mention of intractable epilepsy
34550 Partial epilepsy, without mention of impairment of consciousness without mention of intractable epilepsy
34551 Partial epilepsy, without mention of impairment of consciousness with intractable epilepsy
34560 Infantile spasms without mention of intractable epilepsy
34561 Infantile spasms with intractable epilepsy
34570 Epilepsia partialis continua without mention of intractable epilepsy

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Postoperative Hip Fracture
34571 Epilepsia partialis continua with intractable epilepsy
34580 Other forms of epilepsy without mention of intractable epilepsy
34581 Other forms of epilepsy with intractable epilepsy
34590 Epilepsy, unspecified without mention of intractable epilepsy
34591 Epilepsy, unspecified with intractable epilepsy
78031 Febrile convulsions
78039 Other convulsions
7803 Convulsions (old code no longer valid)

Syncope
ICD-9-CM diagnosis codes:

7802 Syncope and collapse

Stroke
ICD-9-CM diagnosis codes:

430 Subarachnoid hemorrhage

431 Intracerebral hemorrhage
4320 Nontraumatic extradural hemorrhage
4321 Subdural hemorrhage
4329 Unspecified intracranial hemorrhage
436 Acute, but ill-defined cerebrovascular disease
99702 Postoperative cerebrovascular accident

Occlusion and stenosis of precerebral arteries:

43301 Basilar artery, with cerebral infarction
43311 Carotid artery, with cerebral infarction
43321 Vertebral artery - with cerebral infarction
43331 Multiple and bilateral with cerebral infarction
43381 Other specified precerebral artery with cerebral infarction
43391 Occlusion and stenosis of precerebral arteries, unspecified precerebral artery with cerebral infarction

Occlusion of cerebral arteries:

43401 Cerebral thrombosis with cerebral infarction
43411 Cerebral embolism with cerebral infarction
43491 Cerebral artery occlusion, unspecified - with cerebral infarction

Coma
ICD-9-CM diagnosis codes:

2510 Other disorders of pancreatic internal secretion, hypoglycemic coma

5722 Liver abscess and sequelae of chronic liver disease, hepatic coma
78001 General symptoms, alteration of consciousness, coma
25020 Diabetes with hyperosmolarity, type 2 [noninsulin dependent type][NIDDM type][adult-onset] or unspecified
type, not stated as uncontrolled
25021 Diabetes with hyperosmolarity, type 1 [insulin dependent type][IDDM-type] [juvenile type], not stated as
uncontrolled
25022 Diabetes with hyperosmolarity, type 2
25023 Diabetes mellitus, diabetes with hyperosmolarity, type 1 [insulin dependent type][IDDM-type][juvenile type]
uncontrolled
25030 Diabetes with other coma, type 2 not stated as uncontrolled
25031 Diabetes with other coma, type 1 not stated as uncontrolled
25032 Diabetes mellitus, diabetes with other coma, type 2 uncontrolled
25033 Diabetes mellitus, diabetes with other coma, type 1 uncontrolled
78003 General symptoms, alteration of consciousness persistent vegetative state

Cardiac Arrest
ICD-9-CM diagnosis code:

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Postoperative Hip Fracture
4275 Cardiac arrest

Poisoning
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

960 Poisoning by antibiotics

961 Poisoning by other anti-infectives
962 Poisoning by hormones and synthetic substitutes
963 Poisoning by primarily systemic agents
964 Poisoning by agents primarily affecting blood constituents
965 Poisoning by analgesics, antipyretics, and antirheumatics
966 Poisoning by anticonvulsants and anti-parkinsonism drugs
967 Poisoning by sedatives and hypnotics
968 Poisoning by other central nervous system depressants and anesthetics
969 Poisoning by psychotropic agents
970 Poisoning by central nervous system stimulants
971 Poisoning by drugs primarily affecting the autonomic nervous system
972 Poisoning by agents primarily affecting the cardiovascular system
973 Poisoning by agents primarily affecting the gastrointestinal system
974 Poisoning by water, mineral, and uric acid metabolism drugs
975 Poisoning by agents primarily acting on the smooth and skeletal muscles and respiratory system
976 Poisoning by agents primarily affecting skin and mucous membrane, opthamological, otorhinolaryncological
and dental drugs
977 Poisoning by other and unspecified drugs and medicinal substances
978 Poisoning by bacterial vaccines
979 Poisoning by other vaccines and biological substances
E850 Accidental poisoning by analgesics, antipyretics, and antirheumatics
E851 Accidental poisoning by barbiturates
E852 Accidental poisoning by other sedatives and hypnotics
E853 Accidental poisoning by tranquilizers
E854 Accidental poisoning by other psychotropic agents
E855 Accidental poisoning by other drugs acting on central and autonomic nervous system
E856 Accidental poisoning by antibiotics
E857 Accidental poisoning by other anti-infectives
E858 Accidental poisoning by other drugs
E860 Accidental poisoning by alcohol, NEC
E861 accidental poisoning by cleaning and polishing agents, disinfectants, paints, and varnishes
E862 Accidental poisoning by petroleum products, other solvents and their vapors, NEC
E863 Accidental poisoning by agricultural and horticultural chemical and pharmaceutical preparations other than
plant foods and fertilizers
E864 Accidental poisoning by corrosives and caustics, NEC
E865 Accidental poisoning from poisonous foodstuffs and poisonous plants
E866 Accidental poisoning by other and unspecified solid and liquid substances
E867 Accidental poisoning by gas distributed by pipeline
E868 Accidental poisoning by other utility gas and other carbon monoxide
E869 Accidental poisoning by other gases and vapors
E951 Suicide and self-inflicted poisoning by gases in domestic use
E952 Suicide and self-inflicted poisoning by other gases and vapors
E962 Assault by poisoning
E980 Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted
E981 Poisoning by gases in domestic use, undetermined whether accidentally or purposely inflicted
E982 Poisoning by other gases, undetermined whether accidentally or purposely inflicted

Trauma
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

800 Fracture of vault of skull

801 Fracture of base of skull
802 Fracture of face bones
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones

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805 Fracture of vertebral column without mention of spinal cord injury
806 Fracture of vertebral column with spinal cord injury
807 Fracture of rib[s] sternum, larynx, and trachea
808 Fracture of pelvis
809 Ill-defined fractures of bones of trunk
810 Fracture of clavicle
811 Fracture of scapula
812 Fracture of humerous
813 Fracture of radius and ulna
814 Fracture of carpal bone[s]
815 Fracture of metacarpal bone[s]
817 Multiple fracture of hand bones
818 Ill-defined fractures of upper limb
819 Multiple fractures involving both upper limbs, and upper limb with rib and sternum
820 Fracture of neck of femur
821 Fracture of other and unspecified parts of femur
822 Fracture of patella
823 Fracture of tibia and fibula
824 Fracture of ankle
825 Fracture of one or more tarsal and metatarsal bones
827 Other, multiple, and ill-defined fractures of lower limb
828 Multiple fractures involving both lower limbs, lower with upper limb, and lower limb with rib and sternum
829 Fracture of unspecified bones
830 Dislocation of jaw
831 Dislocation of shoulder
832 Dislocation of elbow
833 Dislocation of wrist
835 Dislocation of hip
836 Dislocation of knee
837 Dislocation of ankle
838 Dislocation of foot
839 Other, multiple, and ill-defined dislocations
850 Concussion
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following injury
853 Other and unspecified intracranial hemorrhage following injury
854 Intracranial injury of other and unspecified nature
860 Traumatic pneumothorax
861 Injury to heart and lung
862 Injury to other and unspecified intrathoracic organs
863 Injury to gastrointestinal tract
864 Injury to liver
865 Injury to spleen
866 Injury to kidney
867 Injury to pelvic organs
868 Injury to other intra-abdominal organs
869 Internal injury to unspecified or ill-defined organs
870 Open wound of ocular adnexa
871 Open wound of eyeball
872 Open wound of ear
873 Other open wound of head
874 Open wound of neck
875 Open wound of chest [wall]
876 Open wound of back
877 Open wound of buttock
878 Open wound of genital organs [external] including traumatic amputation
879 Open wound of other and unspecified sites, except limbs
880 Open wound of shoulder and upper arm
881 Open wound of elbow, forearm, and wrist
882 Open wound of hand except finger alone
884 Multiple and unspecified open wound of upper limb
887 Traumatic amputation of arm and hand (complete) (partial)

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Postoperative Hip Fracture
890 Open wound of hip and thigh
891 Open wound of knee, leg (except thigh) and ankle
892 Open wound of foot except toe alone
894 Multiple and unspecified open wound of lower limb
896 Traumatic amputation of foot (complete) (partial)
897 Traumatic amputation of leg[s] (complete) (partial)
900 Injury to blood vessels of head and neck
901 Injury to blood vessels of thorax
902 Injury to blood vessels of abdomen and pelvis
903 Injury to blood vessels of upper extremity
904 Injury to blood vessels of lower extremity and unspecified sites
925 Crushing injury of face, scalp, and neck
926 Crushing injury of trunk
927 Crushing injury of upper limb
928 Crushing injury of lower limb
929 Crushing injury of multiple and unspecified sites
940 Burn confined to eye and adnexa
941 Burn of face, head, and neck
942 Burn of trunk
943 Burn of upper limb, except wrist and hand
944 Burn of wrist[s] and hand[s]
945 Burn of lower limb[s]
946 Burns of multiple specified sites
947 Burn of internal organs
948 Burns classified according to extent of body surface involved
949 Burn, unspecified
952 Spinal chord injury without evidence of spinal bone injury
953 Injury to nerve roots and spinal plexus
958 Certain early complications of trauma

DRGs:

002 Craniotomy for trauma, age greater than 17

027 Traumatic stupor and coma, coma greater than one hour
028 Traumatic stupor and coma, coma less than one hour, age greater than 17 with CC
029 Traumatic stupor and coma, coma less than one hour, age greater than 17 without CC
030 Traumatic stupor and coma, coma less than one hour, age 0-17
031 Concussion, age greater than 17 with CC
032 Concussion, age greater than 17 without CC
033 Concussion, age 0-17
072 Nasal trauma and deformity
083 Major chest trauma with CC
084 Major chest trauma without CC
235 Fractures of femur
236 Fracture of hip and pelvis
237 Sprains, strains and dislocations of hip, pelvis and thigh
440 Wound debridements for injuries
441 Hand procedures for injuries
442 Other OR procedures for injuries with CC
443 Other OR procedures for injuries without CC
444 Traumatic injury, age greater than 17 with CC
445 Traumatic injury, age greater than 17 without CC
446 Traumatic injury, age 0-17
456 No longer valid
457 No longer valid
458 No longer valid
459 No longer valid
460 No longer valid
484 Craniotomy for multiple significant trauma
485 Limb reattachment, hip and femur procedures for multiple significant trauma
486 Other OR procedures for multiple significant trauma
487 Other multiple significant traumas

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Postoperative Hip Fracture
491 Major joint and limb reattachment procedures of upper extremity
504 Total hepatectomy
505 Extensive 3rd degree burns w/o skin graft
506 Full thickness burn with skin graft or inhalation injury with CC or significant trauma
507 Full thickness burn with skin graft or inhalation injury without CC or significant trauma
508 Full thickness burn without skin graft or inhalation injury with CC or significant trauma
509 Full thickness burn without skin graft or inhalation injury without CC or significant trauma
510 Non-extensive burns with CC or significant trauma
511 Non-extensive burns without CC or significant trauma

Delirium and Other Psychoses

ICD-9-CM diagnosis codes (includes 4th and 5th digits):

290 Senile and presenile organic psychotic conditions

291 Alcoholic psychoses
292 Drug psychoses
293 Transient organic psychotic conditions
294 Other organic psychotic conditions
295 Schizophrenic disorders
296 Affective psychoses
297 Paranoid states
298 Other nonorganic psychoses
299 Psychoses with origin specific to childhood

Anoxic Brain Injury

ICD-9-CM diagnosis code:

3481 Anoxic brain damage

Metastatic Cancer
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

196 Secondary and unspecified malignant neoplasm of lymph nodes

197 Secondary malignant neoplasm of respiratory and digestive systems
198 Secondary malignant neoplasm of other specified sites
1990 Malignant neoplasm without specification of site, disseminated

Lymphoid Malignancy
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

200 Lymphosarcoma and reticulosarcoma

201 Hodgkins disease
202 Other malignant neoplasms of lymphoid and histiocytic tissue
203 Multiple myeloma and immunoproliferative neoplasms
204 Lymphoid leukemia
205 Myeloid leukemia
206 Monocytic leukemia
207 Other specified leukemia
208 Leukemia of unspecified cell type

Bone Malignancy
ICD-9-CM diagnosis code (includes 4th and 5th digits):

170 Malignant neoplasm of bone and articular cartilage

Self-Inflicted Injury
ICD-9-CM diagnosis codes:

Suicide and self-inflicted poisoning by solid or liquid substance:

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Postoperative Hip Fracture
E9500 Analgesics, antipyretics, and antirheumatics
E9501 Barbiturates
E9502 Other sedative and hypnotics
E9503 Tranquilizers and other psychotropic agents
E9504 Other specified drugs and medicinal substances
E9505 Unspecified drug or medicinal substance
E9506 Agricultural and horticultural chemical and pharmaceutical preparations other than plant foods and fertilizers
E9507 Corrosive and caustic substances
E9508 Arsenic and its compounds
E9509 Other and unspecified solid and liquid substances

Suicide and self-inflicted poisoning by gases in domestic use:

E9510 Gas distributed by pipeline
E9511 Liquefied petroleum gas distributed in mobile containers
E9518 Other utility gases
E9520 Motor vehicle exhaust gas
E9521 Other carbon monoxide
E9528 Other specified gases and vapors
E9529 Unspecified gases and vapors

Suicide and self-inflicted injury by hanging, strangulation, and suffocation:

E9530 Hanging
E9531 Suffocation by plastic bag
E9538 Other specified means
E954 Suicide and self-inflicted injury by submersion [drowning]

Suicide and self-inflicted injury by firearms and explosives:

E9550 Handgun
E9551 Shotgun
E9552 Hunting rifle
E9553 Military firearms
E9554 Other and unspecified firearms
E9555 Explosives
E9559 Unspecified
E956 Suicide and self inflicted injury by cutting and piercing instrument

Suicide and self-inflicted injury by jumping from a high place:

E9570 Residential premises
E9571 Other man-made structures
E9572 Natural sites
E9573 Unspecified

Suicide and self-inflicted injury by other and unspecified means:

E9580 Jumping or lying before moving object
E9581 Burns, fire
E9582 Scald
E9583 Extremes of cold
E9584 Electrocution
E9585 Crashing of motor vehicle
E9586 Crashing of aircraft
E9587 Caustic substances except poisoning
E9588 Other specified means
E9589 Unspecified means

Postoperative Physiologic and Metabolic Derangement

Numerator:

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Postoperative Physiologic and Metabolic Derangement
Discharges with ICD-9-CM codes for physiologic and metabolic derangements in any secondary
diagnosis field per 1,000 elective surgical discharges.
Discharges with acute renal failure (subgroup of physiologic and metabolic derangements) must
be accompanied by a procedure code for dialysis (3995, 5498).

Physiologic and Metabolic Derangements

ICD-9-CM diagnosis codes:

Diabetes with ketoacidosis:

25010 Type 2, or unspecified type, not stated as uncontrolled
25011 Type 1 not stated as uncontrolled
25012 Type 2, or unspecified type, uncontrolled
25013 Type 1 uncontrolled

Acute renal failure:

5845 With lesion of tubular necrosis
5846 With lesion of renal cortical necrosis
5847 With lesion of renal medullary [papillary] necrosis
5848 With other specified pathological lesion in kidney
5849 Acute renal failure, unspecified

Diabetes with hyperosmolarity:

25020 Type 2, or unspecified type, not stated as uncontrolled
25021 Type 1 not stated as uncontrolled
25022 Type 2, or unspecified type, uncontrolled
25023 Type 1 uncontrolled

Diabetes with other coma:

25030 Type 2, or unspecified type, not stated as uncontrolled
25031 Type 1 not stated as uncontrolled
25032 Type 2, or unspecified type, uncontrolled
25033 Type 1 uncontrolled

Denominator:
All elective surgical discharges defined by admission type and specific DRGs (see denominator
for Complications of Anesthesia for surgical discharges).

Elective

Admission type # is recorded as elective (ATYPE = 3)

Exclude:
Patients with both a diagnosis code of ketoacidosis, hyperosmolarity, or other coma (subgroups
of physiologic and metabolic derangements coding) and a principal diagnosis of diabetes.
Patients with both a secondary diagnosis code for acute renal failure (subgroup of physiologic
and metabolic derangements coding) and a principal diagnosis of acute myocardial infarction,
cardiac arrhythmia, cardiac arrest, shock, hemorrhage, or gastrointestinal hemorrhage.
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).

Diabetes
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

2500 Diabetes mellitus without mention of complication

2501 Diabetes with ketoacidosis
2502 Diabetes with hyperosmolarity

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2503 Diabetes with other coma
2504 Diabetes with renal manifestations
2505 Diabetes with ophthalmic manifestations
2506 Diabetes with neurological manifestations
2507 Diabetes with peripheral circulatory disorders
2508 Diabetes with other specified manifestations
2509 Diabetes with other unspecified complications

Acute Myocardial Infarction

ICD-9-CM diagnosis codes:

41000 AMI of anterolateral wall episode of care unspecified

41001 AMI of anterolateral wall initial episode of care
41010 AMI of other anterior wall episode of care unspecified
41011 AMI of other anterior wall initial episode of care
41020 AMI of inferolateral wall episode of care unspecified
41021 AMI of inferolateral wall initial episode of care
41030 AMI of inferoposterior wall episode of care unspecified
41031 AMI of inferoposterior wall initial episode of care
41040 AMI of inferior wall episode of care unspecified
41041 AMI of inferior wall initial episode of care
41050 AMI of other lateral wall episode of care unspecified
41051 AMI of other lateral wall initial episode of care
41060 AMI true posterior wall infarction episode of care unspecified
41061 AMI true posterior wall infarction initial episode of care
41070 AMI subendocardial infarction episode of care unspecified
41071 AMI subendocardial infarction initial episode of care
41080 AMI of other specified sites episode of care unspecified
41081 AMI of other specified sites initial episode of care
41090 AMI unspecified site episode of care unspecified
41091 AMI unspecified site initial episode of care

Cardiac Arrhythmia
ICD-9-CM diagnosis codes:

4260 Atrioventricular block, complete

4270 Paroxysmal supraventricular tachycardia
4271 Paroxysmal ventricular tachycardia
4272 Paroxysmal tachycardia, unspecified
42731 Atrial fibrillation
42732 Atrial flutter
42741 Ventricular fibrillation
42742 Ventricular flutter
4279 Cardiac dysrhythmia

DRGs:

138 Cardiac arrhythmia and conduction disorders with CC

139 Cardiac arrhythmia and conduction disorders without CC

Cardiac Arrest
ICD-9-CM diagnosis code:

4275 Cardiac arrest

Shock
ICD-9-CM diagnosis codes:

63450 Spontaneous abortion with shock - unspecified

63451 Spontaneous abortion with shock - incomplete

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Postoperative Physiologic and Metabolic Derangement
63452 Spontaneous abortion with shock - complete
63550 Legal abortion with shock - unspecified
63551 Legal abortion with shock - incomplete
63552 Legal abortion with shock - complete
63650 Illegal abortion with shock - unspecified
63651 Illegal abortion with shock - incomplete
63652 Illegal abortion with shock - complete
63750 Abortion NOS with shock - unspecified
63751 Abortion NOS with shock - incomplete
63752 Abortion NOS with shock - complete
6385 Attempted abortion with shock
6395 Complications following abortion and ectopic and molar pregnancies, shock
66910 Shock during or following labor and delivery, unspecified as to episode of care or not applicable
66911 Shock during or following labor and delivery, delivered with or without mention of antepartum condition
66912 Shock during or following labor and delivery, delivered with mention of postpartum complication
66913 Shock during or following labor and delivery, antepartum condition or complication
66914 Shock during or following labor and delivery, postpartum condition or complication
7855 Shock without mention of trauma
78550 Shock, unspecified
78551 Cardiogenic shock
78559 Shock without mention of trauma, other
9950 Other anaphylactic shock
9954 Shock due to anesthesia
9980 Postoperative shock
9994 Anaphylactic shock, due to serum

Hemorrhage
ICD-9-CM diagnosis codes:

2851 Acute posthemorrhagic anemia

4590 Other disorders of circulatory system, hemorrhage, unspecified
9582 Certain early complications of trauma, secondary and recurrent hemorrhage
99811 Hemorrhage complicating a procedure

Gastrointestinal (GI) Hemorrhage

ICD-9-CM diagnosis codes:

4560 Esophageal varices with bleeding

45620 Esophageal varices in diseases classified elsewhere with bleeding
5307 Gastroesophageal laceration hemorrhage syndrome
53082 Esophageal hemorrhage
53100 Gastric ulcer acute with hemorrhage without mention of obstruction
53101 Gastric ulcer acute with hemorrhage with obstruction
53120 Gastric ulcer acute with hemorrhage and perforation without mention of obstruction
53121 Gastric ulcer acute with hemorrhage and perforation with obstruction
53140 Gastric ulcer chronic or unspecified with hemorrhage without mention of obstruction
53141 Gastric ulcer chronic or unspecified with hemorrhage with obstruction
53160 Gastric ulcer chronic or unspecified with hemorrhage and perforation without mention of obstruction
53161 Gastric ulcer chronic or unspecified with hemorrhage and perforation with obstruction
53200 Duodenal ulcer acute with hemorrhage without mention of obstruction
53201 Duodenal ulcer acute with hemorrhage with obstruction
53220 Duodenal ulcer acute with hemorrhage and perforation without mention of obstruction
53221 Duodenal ulcer acute with hemorrhage and perforation with obstruction
53240 Duodenal ulcer chronic or unspecified with hemorrhage without mention of obstruction
53241 Duodenal ulcer chronic or unspecified with hemorrhage with obstruction
53260 Duodenal ulcer chronic or unspecified with hemorrhage and perforation without mention of obstruction
53261 Duodenal ulcer chronic or unspecified with hemorrhage and perforation with obstruction
53300 Peptic ulcer, site unspecified, acute with hemorrhage without mention of obstruction
53301 Peptic ulcer, site unspecified, acute with hemorrhage with obstruction
53320 Peptic ulcer, site unspecified, acute with hemorrhage and perforation without mention of obstruction
53321 Peptic ulcer, site unspecified, acute with hemorrhage and perforation with obstruction

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53340 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage without mention of obstruction
53341 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage with obstruction
53360 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage and perforation without mention of
obstruction
53361 Peptic ulcer, site unspecified, chronic or unspecified with hemorrhage and perforation with obstruction
53400 Gastrojejunal ulcer, acute with hemorrhage without mention of obstruction
53401 Gastrojejunal ulcer, acute with hemorrhage with obstruction
53420 Gastrojejunal ulcer, acute with hemorrhage and perforation without mention of obstruction
53421 Gastrojejunal ulcer, acute with hemorrhage and perforation with obstruction
53440 Gastrojejunal ulcer, chronic or unspecified with hemorrhage without mention of obstruction
53441 Gastrojejunal ulcer, chronic or unspecified with hemorrhage with obstruction
53460 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation without mention of obstruction
53461 Gastrojejunal ulcer, chronic or unspecified with hemorrhage and perforation with obstruction
53501 Gastritis and duodenitis, acute gastritis with hemorrhage
53511 Gastritis and duodenitis, atrophic gastritis with hemorrhage
53521 Gastritis and duodenitis, gastric mucosal hypertrophy, with hemorrhage
53531 Gastritis and duodenitis, alcoholic gastritis, with hemorrhage
53541 Gastritis and duodenitis, other specified gastritis with hemorrhage
53551 Gastritis and duodenitis, unspecified gastritis and gastroduodenitis with hemorrhage
53561 Gastritis and duodenitis, duodenitis with hemorrhage
53783 Other specified disorders of stomach and duodenum, angiodysplasia of stomach and duodenum with
hemorrhage
53784 Dieulafoy lesion (hemorrhagic) of stomach and duodenum
56202 Diverticulosis of small intestine with hemorrhage
56203 Diverticulitis of small intestine with hemorrhage
56212 Diverticulosis of colon with hemorrhage
56213 Diverticulitis of colon with hemorrhage
5693 Hemorrhage of rectum and anus
56985 Angiodysplasia of intestine - with hemorrhage
56986 Dieulafoy lesion (hemorrhagic) of intestine
5780 Gastrointestinal hemorrhage, hematemesis
5781 Gastrointestinal hemorrhage, blood in stool
5789 Gastrointestinal hemorrhage, hemorrhage of gastrointestinal tract, unspecified
Patients with both a secondary diagnosis code for acute renal failure (subgroup of physiologic and metabolic
derangements coding) and a principal diagnosis of acute myocardial infarction, cardiac arrhythmia, cardiac arrest,
shock, hemorrhage, or gastrointestinal hemorrhage. See Failure to Rescue for definitions.

Postoperative Pulmonary Embolism or Deep Vein Thrombosis

Numerator:
Discharges with ICD-9-CM codes for deep vein thrombosis or pulmonary embolism in any
secondary diagnosis field per 1,000 surgical discharges.

Deep Vein Thrombosis

ICD-9-CM diagnosis codes:

45111 Phlebitis and thrombosis of femoral vein (deep) (superficial)

45119 Phlebitis and thrombophlebitis of deep vessel of lower extremities other
4512 Phlebitis and thrombophlebitis of lower extremities unspecified
45181 Phlebitis and thrombophlebitis of iliac vein
4519 Phlebitis and thrombophlebitis of other sites - of unspecified site
4538 Other venous embolism and thrombosis of other specified veins
4539 Other venous embolism and thrombosis of unspecified site

Pulmonary Embolism
ICD-9-CM diagnosis codes:

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Postoperative Pulmonary Embolism or Deep Vein Thrombosis

41511 Iatrogenic pulmonary embolism and infarction

41519 Pulmonary embolism and infarction, other

Denominator:
All surgical discharges defined by specific DRGs (see denominator for Complications of
Anesthesia).
Exclude:
Patients with a principal diagnosis of deep vein thrombosis.
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).
Patients with secondary procedure code 387 when this procedure occurs on the day of or
previous to the day of the principal procedure.

Postoperative Respiratory Failure

Numerator:
Discharges with ICD-9-CM codes for acute respiratory failure (51881) in any secondary diagnosis
field per 1,000 elective surgical discharges. (After 1999, include 51884).
Denominator:
All elective surgical discharges defined by admission type and specific DRGs (see denominator
for Complications of Anesthesia for surgical discharges).

Elective

Admission type # is recorded as elective (ATYPE = 3).

Exclude:
Patients with respiratory or circulatory diseases (MDC 4 and 5).
Obstetrical patients in MDC 14 (Pregnancy, Childbirth, and the Puerperium).

Postoperative Sepsis
Numerator:
Discharges with ICD-9-CM code for sepsis in any secondary diagnosis field per 1,000 elective
surgical discharges.

Sepsis
ICD-9-CM diagnosis codes:
0380 Streptococcal septicemia
03810 Staphylococcal septicemia, unspecified
03811 Staphylococcus aureus septicemia
03819 Other staphylococcal septicemia
0382 Pneumococcal septicemia (streptococcus pneumoniae septicemia)
0383 Septicemia due to anaerobes

Septicemia due to:

03840 Gram-negative organism, unspecified
03841 Hemophilus influenzae
03842 Escherichia coli

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03843 Pseudomonas
03844 Serratia
03849 Septicemia due to other gram-negative organisms
0388 Other specified septicemias
0389 Unspecified septicemia
99591 Systemic inflammatory response syndrome due to infectious process without organ dysfunction
99592 Systemic inflammatory response syndrome due to infectious process with organ dysfunction

Denominator:
All elective surgical discharges (see denominator for Complications of Anesthesia for surgical
discharges).

Elective

Admission type # is recorded as elective (ATYPE = 3)

Exclude:
Patients with a principal diagnosis of infection, or any code for immunocompromised state, or
cancer.
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium)
Include only patients with a length of stay of 4 or more days.

Infection
ICD-9-CM diagnosis codes:

5400 Acute appendicitis with generalized peritonitis

5401 Acute appendicitis with peritoneal abscess
5409 Acute appendicitis without mention of peritonitis
541 Appendicitis, unqualified
542 Other appendicitis
56201 Diverticulitis of small intestine (without mention of hemorrhage)
56203 Diverticulitis of small intestine with hemorrhage
56211 Diverticulitis of colon (without mention of hemorrhage)
56213 Diverticulitis of colon with hemorrhage
566 Abscess of anal and rectal regions
5670 Peritonitis in infectious diseases classified elsewhere
5671 Pneumococcal peritonitis
5672 Other suppurative peritonitis
5678 Other specified peritonitis
5679 Unspecified peritonitis
5695 Abscess of intestine
56961 Infection of colostomy or enterostomy
5720 Abscess of liver
5721 Portal pyemia
57400 Calculus of gallbladder with acute cholecystitis - without mention of obstruction
57401 Calculus of gallbladder with acute cholecystits - with obstruction
57430 Calculus of bile duct with acute cholecystitis without mention of obstruction
57431 Calculus of bile duct with acute cholecystitis - with obstruction
57460 Calculus of gallbladder and bile duct with acute cholecystitis - without mention of obstruction
57461 Calculus of gallbladder and bile duct with acute cholecystitis - with obstruction
57480 Calculus of gallbladder and bile duct with acute and chronic cholecystitis - without mention of obstruction
57481 Calculus of gallbladder and bile duct with acute and chronic cholecystitis - with obstruction
5750 Acute cholecystitis
5754 Perforation of gallbladder
5761 Cholangitis
5763 Perforation of bile duct

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Postoperative Sepsis
DRGs:

020 Nervous system infection except viral meningitis

068 Otitis media and URI, age greater than 17 with CC
069 Otitis media and URI, age greater than 17 without CC
079 Respiratory infections and inflammations, age greater than 17 with CC
080 Respiratory infections and inflammations, age greater than 17 without CC
081 Respiratory infections and inflammations, age 0-17
089 Simple pneumonia and pleurisy, age greater than 17 with CC
090 Simple pneumonia and pleurisy, age greater than 17 without CC
126 Acute and subacute endocarditis
238 Osteomyelitis
242 Septic arthritis
277 Cellulitis, age greater than 17 with CC
278 Cellulitis, age greater than 17 without CC
279 Cellulitis, age 0-17
320 Kidney and urinary tract infections, age greater than 17 with CC
321 Kidney and urinary tract infections, age greater than 17 without CC
322 Kidney and urinary tract infections, age 0-17
368 Infections of female reproductive system
415 OR procedure for infectious and parasitic diseases
416 Septicemia, age greater than 17
417 Septicemia, age 0-17
423 Other infectious and parasitic diseases diagnoses

Immunocompromised States
ICD-9-CM diagnosis codes:

042 Human immunodeficiency virus disease

1363 Pneumocystosis
27900 Hypogammaglobulinemia NOS
27901 Selective IgA immunodeficiency
27902 Selective IgM immunodeficiency
27903 Other selective immunoglobulin deficiencies
27904 Congenital hypogammaglobulinemia
27905 Immunodeficiency with increased IgM
27906 Common variable immunodeficiency
27909 Humoral immunity deficiency NEC
27910 Immunodeficiency with predominent T-cell defect, NOS
27911 DiGeorges syndrome
27912 Wiskott-Aldrich syndrome
27913 Nezelofs syndrome
27919 Deficiency of cell-mediated immunity, NOS
2792 Combined immunity deficiency
2793 Unspecified immunity deficiency
2794 Autoimmune disease, not elsewhere classified
2798 Other specified disorders involving the immune mechanism
2799 Unspecified disorder of immune mechanism

Complications of transplanted organ:

9968 Complications of transplanted organ
99680 Transplanted organ, unspecified
99681 Kidney transplant
99682 Liver transplant
99683 Heart transplant
99684 Lung transplant
99685 Bone marrow transplant
99686 Pancreas transplant
99687 Intestine transplant
99689 Other specified organ transplant

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Postoperative Sepsis
V420 Kidney replaced by transplant
V421 Heart replaced by transplant
V426 Lung replaced by transplant
V427 Liver replaced by transplant
V428 Other specified organ or tissue
V4281 Bone marrow replaced by transplant
V4282 Peripheral stem cells replaced by transplant
V4283 Pancreas replaced by transplant
V4284 Intestines replace by transplant
V4289 Other replaced by transplant

ICD-9-CM procedure codes:

335 Lung transplantation

3350 Lung transplantation, NOS
3351 Unilateral lung transplantation
3352 Bilateral lung transplantation
336 Combined heart-lung transplantation
375 Heart transplantation
410 Operations on bone marow and spleen
4100 Bone marrow transplant, NOS
4101 Autologous bone marrow transplant without purging
4102 Allogenic bone marrow transplant with purging
4103 Allogenic bone marrow transplant without purging
4104 Autologous hematopoietic stem cell transplant without purging
4105 Allogeneic hematopoietic stem cell transplant without purging
4106 Cord blood stem cell transplant
4107 Autologous hematopoietic stem cell transplant with purging
4108 Allogeneic hematopoietic stem cell transplant with purging
4109 Autologous bone marrow transplant with purging
5051 Auxiliary liver transplant
5059 Liver transplant, NEC
5280 Pancreatic transplant, NOS
5281 Reimplantation of pancreatic tissue
5282 Homotranplant of pancreas
5283 Heterotransplant of pancreas
5285 Allotransplantation of cells of islets of Langerhans
5286 Transplantation of cells of islets of Langerhans, NOS
5569 Other kidney transplantation

Cancer
ICD-9-CM diagnosis codes (includes 4th and 5th digits):

140 Malignant neoplasm of lip

141 Malignant neoplasm of tongue
142 Malignant neoplasm of major salivary glands
143 Malignant neoplasm of gum
144 Malignant neoplasm of floor of mouth
145 Malignant neoplasm of other and unspecified parts of mouth
146 Malignant neoplasm of oropharynx
147 Malignant neoplasm of nasopharynx
148 Malignant neoplasm of hypopharynx
149 Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
150 Malignant neoplasm of esophagus
151 Malignant neoplasm of stomach
152 Malignant neoplasm of small intestine, including duodenum
153 Malignant neoplasm of colon
154 Malignant neoplasm of rectum, rectosigmoid junction, and anus
155 Malignant neoplasm of liver and intrahepatic bile ducts
156 Malignant neoplasm of gallbladder and extrahepatic bile ducts
157 Malignant neoplasm of pancreas

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Postoperative Sepsis
158 Malignant neoplasm of retroperitoneum and peritoneum
159 Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
160 Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
161 Malignant neoplasm of larynx
162 Malignant neoplasm of trachea, bronchus, and lung
163 Malignant neoplasm of pleura
164 Malignant neoplasm of thymus, heart, and mediastinum
165 Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170 Malignant neoplasm of bone and articular cartilage
171 Malignant neoplasm of connective and other soft tissue
172 Malignant melanoma of skin
174 Malignant neoplasm of female breast
175 Malignant neoplasm of male breast
176 Karposis sarcoma
179 Malignant neoplasm of uterus, part unspecified
180 Malignant neoplasm of cervix uteri
181 Malignant neoplasm of eye
182 Malignant neoplasm of body of uterus
183 Malignant neoplasm of ovary and other uterine adnexa
184 Malignant neoplasm of other and unspecified female genital organs
185 Malignant neoplasm of other and unspecified female genital organs
186 Malignant neoplasm of testes
187 Malignant neoplasm of penis and other male genital organs
188 Malignant neoplasm of bladder
189 Malignant neoplasm of kidney and other and unspecified urinary organs
190 Malignant neoplasm of eye
191 Malignant neoplasm of brain
192 Malignant neoplasm of other and unspecified parts of nervous system
193 Malignant neoplasm of thyroid gland
194 Malignant neoplasm of other endocrine glands and related structures
195 Malignant neoplasm of other, and ill-defined sites
196 Secondary and unspecified malignant neoplasm of lymph nodes
197 Secondary malignant neoplasm of respiratory and digestive systems
198 Secondary malignant neoplasm of other specified sites
199 Malignant neoplasm without specification of site
200 Lymphosarcoma and reticulosarcoma
201 Hodgkins disease
202 Other malignant neoplasms of lymphoid and histiocytic tissues
203 Multiple myeloma and immunoproliferative neoplasms
204 Lymphoid leukemia
205 Myeloid leukemia
206 Monocytic leukemia
207 Other specified leukemia
208 Leukemia of unspecified cell type
2386 Neoplasm of uncertain behavior of other and unspecified sites and tissues, plasma cells
2733 Macroglobulinemia

Personal history of malignant neoplasm:

V1000 Gastrointestinal tract, unspecified
V1001 Tongue
V1002 Other and unspecified oral cavity and pharynx
V1003 Esophagus
V1004 Stomach
V1005 Large intestine
V1006 Rectum, rectosigmoid junction, and anus
V1007 Liver
V1009 Other
V1011 Bronchus and lung
V1012 Trachea
V1020 Respiratory organ, unspecified
V1021 Larynx
V1022 Nasal cavities, middle ear, and accessory sinuses

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V1029 Other respiratory and intrathoracic organs, other
V103 Breast
V1040 Female genital organ, unspecified
V1041 Cervix uteri
V1042 Other parts of uterus
V1043 Ovary
V1044 Other female genital organs
V1045 Male genital organ, unspecified
V1046 Prostate
V1047 Testes
V1048 Epiddidymis
V1049 Other male genital organs
V1050 Urinary organ, unspecified
V1051 Bladder
V1052 Kidney
V1053 Renal pelvis
V1059 Urinary organs, other
V1060 Leukemia, unspecified
V1061 Lymphoid leukemia
V1062 Myeloid leukemia
V1063 Monocytic leukemia
V1069 Leukemia, other
V1071 Lymphosarcoma and reticulosarcoma
V1072 Hodgkins disease
V1079 Other lymphatic and hematopoietic neoplasms, other
V1081 Bone
V1082 Malignant melanoma of skin
V1083 Other malignant neoplasm of skin
V1084 Eye
V1085 Brain
V1086 Other parts of nervous system
V1087 Thyroid
V1088 Other endocrine glands and related structures
V1089 Other
V109 Unspecified personal history of malignant neoplasm

DRGs:

010 Nervous system neoplasms with CC

011 Nervous system neoplasms without CC
064 Ear, nose, mouth and throat malignancy
082 Respiratory neoplasms
172 Digestive malignancy with CC
173 Digestive malignancy without CC
199 Hepatobiliary diagnostic procedure for malignancy
203 Malignancy of hepatobiliary system or pancreas
239 Pathological fractures and musculoskeletal and connective tissue malignancy
257 Total mastectomy for malignancy with CC
258 Total mastectomy for malignancy without CC
259 Subtotal mastectomy for malignancy with CC
260 Subtotal mastectomy for malignancy without CC
274 Malignant breast disorders with CC
275 Malignant breast disorders without CC
303 Kidney, ureter and major bladder procedures for neoplasm
318 Kidney and urinary tract neoplasms with CC
319 Kidney and urinary tract neoplasms without CC
338 Testes procedures for malignancy
344 Other male reproductive system OR procedures for malignancy
346 Malignancy of male reproductive system with CC
347 Malignancy of male reproductive system without CC
354 Uterine and adnexa procedures for nonovarian/adnexal malignancy with CC
355 Uterine and adnexa procedures for nonovarian/adnexal malignancy without CC

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Postoperative Sepsis
357 Uterine and adnexa procedures for ovarian or adnexal malignancy
363 D and C, conization and radioimplant for malignancy
367 Malignancy of female reproductive system without CC
400 Lymphoma and leukemia with major OR procedures
401 Lymphoma and nonacute leukemia with other OR procedure with CC
402 Lymphoma and nonacute leukemia with other OR procedure without CC
403 Lymphoma and nonacute leukemia with CC
404 Lymphoma and nonacute leukemia without CC
405 Acute leukemia without major or procedure, age 0-17
406 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedures with CC
407 Myeloproliferative disorders or poorly differentiated neoplasms with major OR procedure without CC
408 Myeloproliferative disorders or poorly differentiated neoplasms with other OR procedures
409 Radiotherapy
410 Chemotherapy without acute leukemia as secondary diagnosis
411 History of malignancy without endoscopy
412 History of malignancy with endoscopy
413 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses with CC
414 Other myeloproliferative disorders or poorly differentiated neoplasm diagnoses without CC
473 Acute leukemia without major OR procedure, age greater than 17
492 Chemotherapy with acute leukemia as secondary diagnosis

Postoperative Wound Dehiscence

Numerator:
Discharges with ICD-9-CM code for reclosure of postoperative disruption of abdominal wall
(5461) in any secondary procedure field per 1,000 eligible discharges.
Denominator:
All abdominopelvic surgical discharges.
Exclude:
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).

Abdominopelvic
ICD-9-CM procedure codes:

3804 Incision of aorta

3806 Incision of abdominal arteries
3807 Incision of abdominal veins
3814 Endarterectomy of aorta
3816 Endarterectomy of abdominal arteries
3834 Resection of aorta with anastomosis
3836 Resection of abdominal arteries with anastomosis
3837 Resection of abdominal veins with anastomosis
3844 Resection of aorta, abdominal with replacement
3846 Resection of abdominal arteries with replacement
3847 Resection of abdominal veins with replacement
3857 Ligation and stripping of varicose veins, abdominal veins
3864 Other excision of aorta, abdominal
3866 Other excision of abdominal arteries
3867 Other excision of abdominal veins
3884 Other surgical occlusion of aorta, abdominal
3886 Other surgical occlusion of abdominal arteries
3887 Other surgical occlusion of abdominal veins
391 Intra-abdominal venous shunt
3924 Aorta-renal bypass
3925 Aorta-iliac-femoral bypass

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Postoperative Wound Dehiscence
3926 Other intra-abdominal vascular shunt or bypass
4052 Radical excision of periaortic lymph nodes
4053 Radical excision of iliac lymph nodes
412 Splenotomy
4133 Open biopsy of spleen
4141 Marsupialization of splenic cyst
4142 Excision of lesion or tissue of spleen
4143 Partial splenectomy
415 Total splenectomy
4193 Excision of accessory spleen
4194 Transplantation of spleen
4195 Repair and plastic operations on spleen
4199 Other operations on spleen
4240 Esophagectomy, NOS
4241 Partial esophagectomy
4242 Total esophagectomy
4253 Intrathoracic esophageal anastomosis with interposition of small bowel
4254 Other intrathoracic esophagoenterostomy
4255 Intrathoracic esophageal anastomosis with interposition of colon
4256 Other intrathoracic esophagocolostomy
4263 Antesternal esophageal anastomosis with interposition of small bowel
4264 Other antesternal esophagoenterostomy
4265 Antesternal esophageal anastomosis with interposition of colon
4266 Other antesternal esophagocolostomy
4291 Ligation of esophageal varices
430 Gastrostomy
4319 Other gastrostomy
433 Pyloromyotomy
4342 Local excision of other lesion or tissue of stomach
4349 Other destruction of lesion or tissue of stomach
435 Partial gastrectomy with anastomosis to esophagus
436 Partial gastrectomy with anastomosis to duodenum
437 Partial gastrectomy with anastomosis to jejunum
4381 Partial gastrectomy with jejuna transposition
4389 Other partial gastrectomy
4391 Total gastrectomy with intestinal interposition
4399 Other total gastrectomy
4400 Vagotomy, NOS
4401 Truncal vagotomy
4402 Highly selective vagotomy
4403 Other selective vagotomy
4411 Transabdominal gastroscopy
4415 Open biopsy of stomach
4421 Dilation of pylorus by incision
4429 Other pyloroplasty
4431 High gastric bypass
4439 Other gastroenterostomy
4440 Suture of peptic ulcer, NOS
4441 Suture of gastric ulcer site
4442 Suture of duodenal ulcer site
445 Revision of gastric anastomosis
4461 Suture of laceration of stomach
4463 Closure of other gastric fistula
4464 Gastropexy
4465 Esophagogastroplasty
4466 Other procedures for creation of esophagogastric sphincteric competence
4469 Other repair of stomach
4491 Ligation of gastric varices
4492 Intraoperative manipulation of stomach
4500 Incision of intestine, NOS
4501 Incision of duodenum
4502 Other incision of small intestine

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Postoperative Wound Dehiscence
4503 Incision of large intestine
4531 Other local excision of lesion of duodenum
4532 Other destruction of lesion of duodenum
4533 Local excision of lesion or tissue of small intestine, except duodenum
4534 Other destruction of lesion of small intestine, except duodenum
4541 Excision of lesion or tissue of large intestine
4549 Other destruction of lesion of large intestine
4550 Isolation of intestinal segment, NOS
4551 Isolation of segment of small intestine
4552 Isolation of segment of large intestine
4561 Multiple segmental resection of small intestine
4562 Other partial resection of small intestine
4563 Total removal of small intestine
4571 Multiple segmental resection of large intestine
4572 Cesectomy
4573 Right hemicolectomy
4574 Resection of transverse colon
4575 Left hemicolectomy
4576 Sigmoidectomy
4579 Other partial excision of large intestine
458 Total intra-abdominal colectomy
4590 Intestinal anastomosis, NOS
4591 Small-to-small intestinal anastomosis
4592 Anastomosis of small intestine to rectal stump
4593 Other small-to-large intestinal anastomosis
4594 Large-to-large intestinal anastomosis
4595 Anastomosis to anus
4601 Exteriorization of small intestine
4603 Exteriorization of large intestine
4610 Colostomy, NOS
4611 Temporary colostomy
4613 Permanent colostomy
4620 Ileostomy, NOS
4621 Temporary ilesostomy
4622 Continent ileostomy
4623 Other permanent ileostomy
4640 Revision of intestina stoma, NOS
4641 Revision of stoma of small intestine
4642 Repair of pericolostomy hernia
4643 Other revision of stoma of large intestine
4650 Closure of intestinal stoma, NOS
4651 Closure of stoma of small intestine
4652 Closure of stoma of large intestine
4660 Fixation of intestine, NOS
4661 Fixation of small intestine to abdominal wall
4662 Other fixation of small intestine
4663 Fixation of large intestine to abdominal wall
4664 Other fixation of large intestine
4672 Closure of fistula of duodenum
4674 Closure of fistula of small intestine, except duodenum
4676 Closure of fistula of large intestine
4680 Intra-abdominal manipulation of intestine, NOS
4681 Intra-abdominal manipulation of small intestine
4682 Intra-abdominal manipulation of large intestine
4691 Myotomy of sigmoid colon
4692 Myotomy of other parts of colon
4693 Revision of anastomosis of small intestine
4694 Revision of anastomosis of large intestine
4699 Other operations on intestines
4709 Other appendectomy
4719 Other incidental appendectomy
472 Drainage of appendiceal abscess

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Postoperative Wound Dehiscence
4791 Appendectomy
4792 Closure of appendiceal fistula
4799 Other operations on appendix, other
4841 Submucosal resection of rectum
4849 Other pull-through resection of rectum
485 Abdominoperineal resection of rectum
4875 Abdominal proctopexy
500 Hepatotomy
5012 Open biopsy of liver
5021 Marsupialization of lesion of liver
5022 Partial hepatectomy
5029 Other destruction of lesion of liver
503 Lobectomy of liver
504 Total hepatectomy
5051 Auxiliary liver transplant
5059 Other transplant of liver
5069 Other repair of liver
5103 Other cholecystostomy
5104 Other cholecystotomy
5113 Open biopsy of gallbladder or bile ducts
5121 Other partial cholecystectomy
5122 Cholecystectomy
5131 Anastomosis of gallbladder to hepatic ducts
5132 Anastomosis of gallbladder to intestine
5133 Anastomosis of gallbladder to pancreas
5134 Anastomosis of gallbladder to stomach
5135 Other gallbladder anastomosis
5136 Choledochoenterostomy
5137 Anastomosis of hepatic duct to gastrointestinal tract
5139 Other bile duct anastomosis
5141 Common duct exploration for removal of calculus
5142 Common duct exploration for relief of other obstruction
5143 Insertion of choledochohepatic tube for decompression
5149 Incision of other bile ducts for relief of obstruction
5151 Exploration of common duct
5159 Incision of other bile duct
5161 Excision of cystic duct remnant
5162 Excision of ampulla of vater with reimplantation of common duct
5163 Other excision of common duct
5169 Excision of other bile duct
5171 Simple suture of common bile duct
5172 Choledochoplasty
5179 Repair of other bile ducts
5181 Dilation of sphincter of Oddi
5182 Pancreatic sphincterotomy
5183 Pancreatic sphincteroplasty
5189 Other operations on sphincter of Oddi
5192 Closure of cholecystostomy
5193 Closure of other biliary fistula
5194 Revision of anastomosis of biliary tract
5195 Removal of prosthetic device from bile duct
5199 Other operations on biliary tract
5201 Drainage of pancreatic cyst by catheter
5209 Other pancreatotomy
5212 Open biopsy of pancreas
5222 Other excision or destruction of lesion or tissue of pancreas or pancreatic duct
523 Marsupialization of pancreatic cyst
524 Internal drainage of pancreatic cyst
5251 Proximal pancreatectomy
5252 Distal pancreatectomy
5253 Radical subtotal pancreatectomy
5259 Other partial pancreatectomy

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Postoperative Wound Dehiscence
526 Total pancreatectomy
527 Radical pancreaticoduodenectomy
5280 Pancreatic transplant, NOS
5281 Reimplantation
5282 Homotransplant of pancreas
5283 Heterotransplant of pancreas
5292 Cannulation of pancreatic duct
5295 Other repair of pancreas
5296 Anastomosis of pancreas
5299 Other operations on pancreas
5300 Unilateral repair of inguinal hernia, NOS
5301 Repair of direct inguinal hernia
5302 Repair of indirect inguinal hernia
5303 Repair of direct inguinal hernia with graft or prosthesis
5304 Repair of indirect inguinal hernia with graft or prosthesis
5305 Repair of inguinal hernia with graft or prosthesis, NOS
5310 Bilateral repair of inguinal hernia, NOS
5311 Bilateral repair of direct inguinal hernia
5312 Bilateral repair of indirect inguinal hernia
5313 Bilateral repair of inguinal hernia, one direct and one indirect
5314 Bilateral repair of direct inguinal hernia with graft or prosthesis
5315 Bilateral repair of indirect inguinal hernia with graft or prosthesis
5316 Bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis
5317 Bilateral inguinal hernia repair with graft or prosthesis, NOS
5321 Unilateral repair of femoral hernia
5329 Other unilateral femoral herniorrhaphy
5331 Bilateral repair of femoral hernia with graft or prosthesis
5339 Other bilateral femoral herniorrhaphy
5341 Repair of umbilical hernia with prosthesis
5349 Other umbilical herniorrhaphy
5351 Incisional hernia repair
5359 Repair of other hernia of anterior abdominal wall
5361 Incisional hernia repair with prosthesis
5369 Repair of other hernia of anterior abdominal wall with prosthesis
537 Repair of diaphragmatic hernia, abdominal approach
540 Incision of abdominal wall
5411 Exploratory laparotomy
5419 Other laparotomy
5422 Biopsy of abdominal wall or umbilicus
5423 Biopsy of abdominal wall or umbilicus
543 Excision or destruction of lesion or tissue of abdominal wall or umbilicus
544 Excision or destruction of peritoneal tissue
5459 Other lysis of peritoneal adhesions
5463 Other suture of abdominal wall
5464 Suture of peritoneum
5471 Repair of gastroschisis
5472 Other repair of abdominal walls
5473 Other repair of peritoneum
5474 Other repair of omentum
5475 Other repair of mesentery
5492 Removal of foreign body from peritoneal cavity
5493 Creation of cutaneoperitoneal fistula
5494 Creation of peritoneovascular shunt
5495 Incision of peritoneum
5551 Nephroureterectomy
5552 Nephrectomy of remaining kidney
5553 Removal of transplanted or regected kidney
5554 Bilateral nephrectomy
5561 Renal autotransplantation
5569 Ulcerative colitis, unspecified
557 Nephropexy
5583 Closure of other fistula of kidney

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Postoperative Wound Dehiscence
5584 Reduction of torsion of renal
5585 Symphysiotomy for horeshoe kidney
5586 Anastomosis of kidney
5587 Correction of ureteropelvic junction
5591 Decapsulation of kidney
5597 Implantation or replacement of mechanical kidney
5598 Removal of mechanical kidney
5651 Formation of cutaneous uretero-ileostomy
5652 Revision of cutaneous uretero-ileostomy
5661 Formation of other cutaneous ureterostomy
5662 Revision of other cutaneous ureterostomy
5671 Urinary diversion to intestine
5672 Revision of ureterointestinal anastomosis
5673 Nephrocystanastomosis, NOS
5674 Ureteroneoxystostomy
5675 Transureteroureterostomy
5683 Closure of ureterostomy
5684 Closure of other fistula of ureter
5685 Ureteropexy
5686 Removal of ligature from ureter
5689 Other repair of ureter
5695 Ligation of ureter
5771 Radical cystectomy
5779 Other total cystectomy
5782 Closure of cystostomy
5787 Reconstruction of urinary bladder
5900 Retroperitoneal dissection, NOS
5902 Other lysis of perirenal or periureteral adhesions
5909 Other incision of perirenal or periureteral tissue
6012 Open biopsy of prostate
6014 Open biopsy of seminal vesicles
6015 Biopsy of periprostatic tissue
603 Suprapubic prostatectomy
604 Retropubic prostatectomy
605 Radical prostatectomy
6061 Local excision of lesion of prostate
6072 Incision of seminal vesicle
6073 Excision of seminal vesicle
6079 Other operations on seminal vesicles
6093 Repair of prostate
6509 Other oophorectomy
6512 Other biopsy of ovary
6521 Marsupialization of ovarian cyst
6522 Wedge resection of ovary
6529 Other local excision or destruction of ovary
6539 Other unlilateral oophorectomy
6549 Other unilateral salpingoophorectomy
6551 Other removal of both ovaries at same operative episode
6552 Other removal of remaining ovary
6561 Other removal of both ovaries and tubes at same operative episode
6562 Other removal of remaining ovary and tube
6571 Other simple suture of ovary
6572 Other reimplantation of ovary
6573 Other salpingo oophoroplasty
6579 Other repair of ovary
6589 Other lysis of adhesions of ovary and fallopian tube
6592 Transplantation of ovary
6593 Manual rupture of ovarian cyst
6594 Ovarian denervation
6595 Release of torsion of ovary
6599 Other operations on ovary
6601 Salpingotomy

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Postoperative Wound Dehiscence
6602 Salpingostomy
6631 Other bilateral ligation and crushing of fallopian tubes
6632 Other bilateral ligation and division of fallopian tubes
6639 Other bilateral destruction or occlusion of fallopian tubes
664 Total unilateral salpingectomy
6651 Removal of both fallopian tubes at same operative episode
6652 Removal of remaining fallopian tube
6661 Excision or destruction of lesion of fallopian tube
6662 Salpingectomy with removal of tubal pregnancy
6663 Bilateral partial salpingectomy, NOS
6669 Other partial salpingectomy
6671 Simple suture of fallopian tube
6672 Salpingo-oophorostomy
6673 Salpingo-salpingostomy
6674 Salpingo-uterostomy
6679 Other repair of fallopian tube
6692 Unilateral destruction or occlusion of fallopian tube
6697 Burying of fimbriae in uterine wall
680 Other incision and excision of uterus
6813 Open biopsy of uterus
6814 Open biopsy of uterine ligaments
683 Subtotal abdominal hysterectomy
684 Total abdominal hysterectomy
686 Radical abdominal hysterectomy
688 Pelvic evisceration
6922 Other uterine suspension
693 Paracervical uterine denervation
6941 Suture of laceration of uterus
6942 Closure of fistula of uterus
6949 Other repair of uterus

Accidental Puncture or Laceration

Numerator:
Discharges with ICD-9-CM code denoting accidental cut, puncture, perforation or laceration
during a procedure in any secondary diagnosis field per 1,000 discharges.

Accidental Puncture or Laceration

ICD-9-CM diagnosis codes:
Accidental cut, puncture, perforation, or hemorrhage during medical care:
E8700 Surgical operation
E8701 Infusion or transfusion
E8702 Kidney dialysis or other perfusion
E8703 Injection or vaccination
E8704 Endoscopic examination
E8705 Aspiration of fluid or tissue, puncture, and catheterization
E8706 Heart catheterization
E8707 Administration of enema
E8708 Other specified medical care
E8709 Unspecified medical care

9982 Accidental puncture or laceration during a procedure

Denominator:

Version 2.1 133 Revision 1 (May 28, 2003)

Accidental Puncture or Laceration
All medical and surgical discharges defined by specific DRGs (see denominators for
Complications of Anesthesia for surgical discharges and Decubitus Ulcer for medical
discharges).
Exclude:
Obstetrical patients in MDC 14 (Pregnancy, Childbirth and the Puerperium).

Transfusion Reaction
Numerator:
Discharges with ICD-9-CM codes for transfusion reaction in any secondary diagnosis field per
1,000 discharges.

Transfusion Reaction
ICD-9-CM diagnosis codes:

9996 ABO incompatibility reaction

9997 RH incompatibility reaction
E8760 Mismatched blood in transfusion

Denominator:
All medical and surgical discharges defined by specific DRGs (see denominators for
Complications of Anesthesia for surgical discharges and Decubitus Ulcer for medical
discharges).

Birth TraumaInjury to Neonate

Numerator:
Discharges with ICD-9-CM codes for birth trauma in any diagnosis field per 1,000 liveborn births.

Birth Trauma
ICD-9-CM diagnosis codes:
7670 Subdural and cerebral hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
7673 Injuries to skeleton (excludes clavicle)
7674 Injury to spine and spinal cord
7677 Other cranial and peripheral nerve injuries
7678 Other specified birth trauma
7679 Birth trauma, unspecified

Denominator:
All liveborn infants.

Liveborn
DRGs:

385 Neonates, died or transferred to another acute care facility

386 Extreme Immaturity or respiratory distress syndrome of neonate
387 Prematurity with major problems
388 Prematurity without major problems

Version 2.1 134 Revision 1 (May 28, 2003)

Birth TraumaInjury to Neonate
389 Full term neonate with major problems
390 Neonate with other significant problems
391 Normal newborn

AND

ICD-9-CM diagnosis codes (includes 4th and 5th digits):

.
Admission type recorded as (4):
764 Slow fetal growth and fetal malnutrition
765 Disorders relating to short gestation and unspecified low birth weight
766 Disorders relating to long gestation and high birth weight
767 Birth trauma
768 Intrauterine hypoxia and birth asphyxia
769 Respiratory distress syndrome
770 Other respiratory conditions of fetus and newborn
771 Infections specific to the perinatal period
772 Fetal and neonatal hemorrhage
773 Hemolytic disease of fetus or newborn, due to isoimmunization
774 Other perinatal jaundice
775 Endocrine and metabolic disturbances specific to the fetus and newborn
776 Hematological disorders of fetus and newborn
777 Perinatal disorders of digestive system
778 Conditions involving the integument and temperature regulation of fetus and newborn
779 Other and ill-defined conditions originating in the perinatal period
V30 Single liveborn
V31 Twin, mate liveborn
V32 Twin, mate stillborn
V33 Twin, unspecified
V34 Other multiple, mates all liveborn
V35 Other multiple, mates all stillborn
V36 Other multiple, mates live- and stillborn
V37 Other multiple, unspecified
V39 Unspecified

Exclude:
Infants with a subdural or cerebral hemorrhage (subgroup of birth trauma coding - 7670) and any
diagnosis code of pre-term infant (denoting a birth weight of less than 2,500 grams and less than
37 weeks gestation, or 34 weeks gestation or less).
Infants with injury to skeleton (7673, 7674) and any diagnosis code of osteogenesis imperfecta
(75651).

Preterm infant
ICD-9-CM diagnosis codes:

76501 Extreme immaturity, less than 500 grams

76502 Extreme immaturity, 500 749 grams
76503 Extreme immaturity, 750 999 grams
76504 Extreme immaturity, 1000 1249 grams
76505 Extreme immaturity, 1250 1499 grams
76506 Extreme immaturity, 1500 1749 grams
76507 Extreme immaturity, 1750 1999 grams
76508 Extreme immaturity, 2000 2499 grams
76511 Other preterm infants, less than 500 grams
76512 Other preterm infants, 500 749 grams
76513 Other preterm infants, 750 999 grams
76514 Other preterm infants, 1000 1249 grams
76515 Other preterm infants, 1250 1499 grams
76516 Other preterm infants, 1500 1749 grams

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Birth TraumaInjury to Neonate
76517 Other preterm infants, 1750 1999 grams
76518 Other preterm infants, 2000 2499 grams
76521 Less than 24 completed weeks of gestation
76522 24 completed weeks of gestation
76523 25-26 completed weeks of gestation
76524 27-28 completed weeks of gestation
76525 29-30 completed weeks of gestation
76526 31-32 completed weeks of gestation
76527 33-34 completed weeks of gestation

Obstetric TraumaCesarean Delivery

Numerator:
Discharges with ICD-9-CM codes for obstetric trauma in any diagnosis or procedure field per
1,000 cesarean deliveries.

Obstetric Trauma
ICD-9-CM diagnosis codes:

66430,1,4 Trauma to perineum and vulva during delivery, fourth degree perineal laceration
66530,1,4 Other obstetrical trauma, laceration of cervix
66540,1,4 Other obstetrical trauma, high vaginal lacerations
66550,1,4 Other obstetrical trauma, other injury to pelvic organs

ICD-9-CM procedure codes:

7550 Repair of current obstetric lacerations of uterus

7551 Repair of current obstetric lacerations of cervix
7552 Repair of current obstetric lacerations of corpus uteri
7561 Repair of current obstetric laceration of bladder and urethra
7562 Repair of current obstetric laceration of rectum and sphincter ani

Denominator:
All cesarean delivery discharges.

Cesarean Delivery
DRGs:

370 Cesarean section with CC

371 Cesarean section without CC

Obstetric TraumaVaginal Delivery with Instrument

Numerator:
Discharges with ICD-9-CM codes for obstetric trauma in any diagnosis or procedure field per
1,000 instrument-assisted vaginal deliveries.

Obstetric Trauma
ICD-9-CM diagnosis codes:

66430,1,4 Trauma to perineum and vulva during delivery, fourth degree perineal laceration
66530,1,4 Other obstetrical trauma, laceration of cervix

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Obstetric TraumaVaginal Delivery with Instrument
66540,1,4 Other obstetrical trauma, high vaginal lacerations
66550,1,4 Other obstetrical trauma, other injury to pelvic organs

ICD-9-CM procedure codes:

7550 Repair of current obstetric lacerations of uterus

7551 Repair of current obstetric lacerations of cervix
7552 Repair of current obstetric lacerations of corpus uteri
7561 Repair of current obstetric laceration of bladder and urethra
7562 Repair of current obstetric laceration of rectum and sphincter ani

Denominator:
All vaginal delivery discharges with any procedure code for instrument-assisted delivery.

Vaginal Delivery
DRGs:

372 Vaginal delivery with complicating diagnoses

373 Vaginal delivery without complicating diagnoses
374 Vaginal delivery with sterilization and/or D and C
375 Vaginal delivery with OR procedure except sterilization and/or D and C

Instrument-Assisted Delivery
ICD-9-CM procedure codes:

720 Low forceps operation

721 Low forceps operation with episiotomy
7221 Mid forceps operation with episiotomy
7229 Other mid forceps operation
7231 High forceps operation with episiotomy
7239 Other high forceps operation
724 Forceps rotation of fetal head
7251 Partial breech extraction with forceps to aftercoming head
7253 Total breech extraction with forceps to aftercoming head
726 Forceps application to aftercoming head
7271 Vacuum extraction with episiotomy
728 Other specified instrumental delivery
729 Unspecified instrumental delivery

Obstetric TraumaVaginal Delivery without Instrument

Numerator:
Discharges with ICD-9-CM codes for obstetric trauma in any diagnosis or procedure field per
1,000 vaginal deliveries without instrument assistance.

Obstetric Trauma
ICD-9-CM diagnosis codes:

66430,1,4 Trauma to perineum and vulva during delivery, fourth degree perineal laceration
66530,1,4 Other obstetrical trauma, laceration of cervix
66540,1,4 Other obstetrical trauma, high vaginal lacerations
66550,1,4 Other obstetrical trauma, other injury to pelvic organs

ICD-9-CM procedure codes:

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Obstetric TraumaVaginal Delivery without Instrument

7550 Repair of current obstetric lacerations of uterus

7551 Repair of current obstetric lacerations of cervix
7552 Repair of current obstetric lacerations of corpus uteri
7561 Repair of current obstetric laceration of bladder and urethra
7562 Repair of current obstetric laceration of rectum and sphincter ani

Denominator:
All vaginal delivery discharge patients.

Vaginal Delivery
DRGs:

372 Vaginal delivery with complicating diagnoses

373 Vaginal delivery without complicating diagnoses
374 Vaginal delivery with sterilization and/or D and C
375 Vaginal delivery with OR procedure except sterilization and/or D and C
Exclude:
Instrument-assisted delivery.

Instrument-Assisted Delivery
ICD-9-CM procedure codes

720 Low forceps operation

721 Low forceps operation with episiotomy
7221 Mid forceps operation with episiotomy
7229 Other mid forceps operation
7231 High forceps operation with episiotomy
7239 Other high forceps operation
724 Forceps rotation of fetal head
7251 Partial breech extraction with forceps to aftercoming head
7253 Total breech extraction with forceps to aftercoming head
726 Forceps application to aftercoming head
7271 Vacuum extraction with episiotomy
728 Other specified instrumental delivery
729 Unspecified instrumental delivery

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Appendix B: Detailed Methods

Empirical analyses were conducted to provide additional information about the indicators. These
analyses were intended not as decision making tools, but rather explorations into the characteristics of
the indicators. Specifically, these analyses explore the frequency and variation of the indicators, the
potential bias, based on limited risk adjustment, and the relationship between indicators.

Analysis Approach

Data sources. The data sources used in the empirical analyses were the 1997 Florida State
Inpatient Database (SID) (for initial testing and development; 1995-1997 used for persistence analysis)
and the 1997 State Inpatient Databases (SID) for 19 HCUP participating States, referred to in this report
as the National SID (for the final empirical analysis). The Florida SID consists of about 2 million
discharges from over 200 hospitals, and was chosen because Florida is a large diverse State. The
National SID consists of about 19 million discharges from over 2,300 hospitals. The National SID
contains all-payer data on hospital inpatient stays from participating States (Arizona, California, Colorado,
Connecticut, Florida, Illinois, Iowa, Kansas, Maryland, Massachusetts, Missouri, New Jersey, New York,
Oregon, Pennsylvania, South Carolina, Tennessee, Washington, and Wisconsin). All discharges from
participating States community hospitals are included in the SID database, which defines community
hospitals as non-Federal, short-term, general, and other specialty hospitals, excluding long-term hospitals
and hospital units of long-term care institutions, psychiatric hospitals, and alcoholism and chemical
dependency treatment facilities.

A complete description of the content of the SID, including details of the participating States
discharge abstracts, can be found on the Agency for Healthcare Research and Quality Web site
(www.ahrq.gov/data/hcup/hcupsid.htm). Because the Florida SID was used only for initial testing and
development, the empirical results reported are from the National SID. Descriptive results from the
Florida SID are reported for comparison to ensure that the hospital-level results were similar in both data
sources. Differences between Florida and national results are pointed out in the text. The National SID
data were also used for the construction of area measures, with data from the U.S. Census Bureau used
to construct the denominator of these rates.

Reported patient safety indicators. Three sets of patient safety indicators were examined. First,
the Accepted patient safety indicators met the face validity criteria established through the literature
review and clinician panel review. Second, the Experimental patient safety indicators did not meet those
criteria, but appeared to warrant further testing and evaluation. Third, several Accepted patient safety
indicators were modified into area indicators, which were designed to assess the total incidence of the
adverse event within geographic areas. For example, the project team constructed an indicator for
Transfusion reaction at both the hospital and area levels. Transfusion reactions that occur after
discharge from a hospitalization would result in a readmission. The area-level indicator includes these
cases, while the hospital level restricts the number of transfusion reactions to only those that occur during
the same hospitalization that exposed the patient to this risk.

All potential indicators were examined empirically by developing and conducting statistical tests
for precision, bias, and relatedness of indicators. For each indicator, the project team calculated five
different estimates of hospital performance:

1. The raw indicator rate was calculated using the number of adverse events in the numerator divided
by the number of discharges in the population at risk by hospital. For the area indicators, the
denominator is the population of the Metropolitan Statistical Area (MSA), New England County
Metropolitan Area (for the New England States) or county (for non-MSA areas) of the hospital.

2. The raw indicator was adjusted using a logistic regression to account for differences among hospitals
(and areas) in demographics (specifically, age and gender). Age was modeled using a set of dummy
variables to represent 10-year categories except for young children, whose age categories are
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 narrower (i.e., less than 1, 1-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85 or more
years), along with a parallel set of age-gender interactions. Because of sparse cells, certain age
categories were combined or omitted for selected indicators, such as the obstetric indicators.

3. The raw indicator was adjusted to account for differences among hospitals in age, gender and
modified DRG category (as described below).

4. The raw indicator was adjusted to account for differences among hospitals in age, gender, modified
DRG, and comorbidities (defined using an adaptation of the AHRQ comorbidity software) of patients.

5. Multivariate signal extraction (MSX) methods were applied to adjust for reliability by estimating the
amount of noise (i.e., variation due to random error) relative to the amount of signal (i.e.,
systematic variation in hospital performance or the reliability) for each indicator. This or similar
reliability adjustment has been used in the literature for similar purposes.125 126 Mutlivariate methods
(taking into account correlations among indicators to extract additional signal) were applied to most of
the accepted indicators. The exceptions were Death in Low Mortality DRGs and Failure to Rescue.
Only univariate signal extraction methods (smoothing) were applied to these two indicators and to the
experimental indicators, because these indicators possibly cover broader clinical concepts.
Correlations between these indicators and other indicators may not reflect correlations due to quality
of care, and thus inclusion of these indicators may adversely affect the MSX approximations.

For additional details on the empirical methods, refer to the companion EPC HCUP Quality Indicator
Report, published by AHRQ (http://www.ahrq.gov/data/hcup/qirefine.htm). Additional details on the
modifications made to the DRG and comorbidity categories are described below.

Hospital Fixed Effects. In the risk-adjustment models, hospital fixed effects were calculated using
the standard method with logistic models of first estimating the predicted value for each discharge, then
subtracting the actual outcome from the predicted, and averaging the difference for each hospital to get
the hospital fixed effect estimate. In the Quality Indicator Report,127 linear regression models were used
with hospital fixed effects included, arguing that the logistic approach yielded biased estimates due to the
omission of a variable (the hospital) correlated with both the dependent (e.g., in-hospital mortality) and
the independent (e.g., age, gender, APR-DRG) variables in the model. Given the rare occurrence of
many of the PSIs, however, the logistic approach may be more appropriate for this application. Linear
methods assume that the error term is normally distributed. This assumption is violated when the
outcome is dichotomous.

The QI means were generally an order of magnitude higher than the PSI means, so the
assumption was not as problematic. However, the most appropriate method depends on the particular
characteristics of each indicator, whether QI or PSI. To the extent that bias is a concern, accounting for
the clustering of patients by using a hospital fixed effect is advantageous. To the extent that extreme
values are a concern, imposing structure on the error term with logistic methods is advantageous. In the
end, the two approaches can be compared in terms of how much difference it makes in the relative
assessment of provider performance. This issue warrants further analysis to better understand the trade-
offs and limitations of each approach, and under what conditions and for what indicators each approach
might best apply.

Specifically, the risk-adjusted raw estimate of a hospitals performance is constructed in two

steps. In the first step, if it is denoted whether or not the event associated with a particular indicator Yk
(k=1,,K) was observed for a particular patient i in year t (t=1,,T), then the regression to construct a
risk-adjusted raw estimate of a particular patients performance on each indicator can be written as:
125
Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual
physician report cards for assessing the costs and quality of care of a chronic disease JAMA 1999;28(22):2098-105.
126
Christiansen CL, Morris CN. Improving the statistical approach to health care provider profiling. Ann Intern Med
1997;127(8 Pt 2):764-8).
127
Davis et al. 2001.

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(1) Ykit = Zit kt + kit , where

Ykit is the kth PSI for patient i in year t (i.e., whether or not the event associated with the indicator
occurred on that discharge).

Zit is a vector of patient covariates for patient i in year t (i.e., the patient-level measures used as risk
adjusters).

kt is a vector of parameters in each year t, giving the effect of each patient risk adjuster on indicator k
(i.e., the magnitude of the risk adjustment associated with each patient measure).

kit is the unexplained residual in this patient-level model.

In the second step, the hospital effect was estimated by subtracting the resulting predictions from
this patient-level regression from the actual observed patient-level outcomes, and taking the mean of this
difference for each hospital. That is, for each hospital j (j=1,,J),

(2) Mkjt = Ykijt (Zit kt + kit), where

Mkjt is the raw adjusted measure for indicator k for hospital j in year t (i.e., the hospital fixed effect in
the patient-level regression).

Zit is the vector of patient covariates for patient i in year t estimated in Step 1.

In addition to age, sex, and age*sex interactions as adjusters in the model, the project team also
included a modified DRG and comorbidity category for the admission.

Modified DRG Categories. Two modifications were made to the Centers for Medicare and
Medicaid Services (CMS, formerly Health Care Financing Administration) DRGs. First, adjacent DRG
categories that were separated by the presence or absence of comorbidities or complications were
collapsed. For example, DRGs 076 (Other Resp System Operating Room Procedures w CC) and 077
(Other Resp System Operating Room Procedures w/o CC) were grouped into one category. The purpose
was to avoid adjusting for the complication the team was trying to measure. Second, most of the super-
MDC DRG categories were excluded from the logistic models. Excluding these categories also avoids
adjusting for the complications the team was trying to measure. For example, tracheostomies (DRG 482-
483) often result from potentially preventable respiratory complications that require long-term mechanical
ventilation. Similarly, operating room procedures unrelated to the principal diagnosis (DRG 468, 477)
often result from potentially preventable complications that require surgical repair (i.e., fractures,
lacerations).

In the companion technical report on quality indicators, the risk adjustment method implemented
All Patient Refined (APR)-DRGs, a refinement of DRGs to capture different levels of complications.
However, patient safety indicators, designed to detect potentially preventable complications, require a risk
adjustment approach that does not inherently remove the differences between patients based on their
complications. The APR-DRGs could be modified to remove applicable complications, on an indicator-by-
indicator basis, but implementation of such an approach was beyond the scope of the current project. In
this report, APR-DRG risk adjustment was not implemented.

Modified Comorbidity Software. To adjust for comorbidities, the project team used an updated
adaptation of AHRQ Comorbidity Software (http://www.ahrq.gov/data/hcup/comorbid.htm). The ICD-9-
CM codes used to define the comorbidity categories were modified to address four main issues.

1. Comorbidity categories were excluded in the current software that include conditions likely to
represent potentially preventable complications in certain settings, such as after elective surgery.
Specifically, three DRG categories (cardiac arrhythmia, coagulopathy, and fluid/electrolyte disorders)
were removed from the comorbidity adjustment.

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2. Most adaptations were designed to capture acute sequelae of chronic comorbidities, where both
conditions are represented by a single ICD-9-CM code. For example, the definition of hypertension
was broadened to include malignant hypertension, which usually arises in the setting of chronic
hypertension. Unless these "acute on chronic" comorbidities are captured, some patients with
especially severe comorbidities would be mislabeled as not having conditions of interest.

3. The comorbidity definitions did not include obstetric comorbidity codes, which are relevant for the
obstetric indicators. Codes, when available, for these comorbidities in obstetric patients were added.

4. Slight updating was necessary based on recent ICD-9-CM code changes.

Low Mortality DRGs. In order to be included in the Low Mortality DRG indicator, the DRG had
to have an overall in-hospital mortality rate (based on the National SID sample) of less than 0.5%. In
addition, if a DRG category was split based on the presence of comorbidities or complications, then the
category was included only if both DRGs (with and without comorbidities or complications) met the
mortality threshold. Otherwise, the category was not included in the Low mortality DRG PSI. The
indicator is reported as a single measure and stratified into medical (adult and pediatric), surgical (adult
and pediatric), neonatal, obstetric and psychiatric DRGs.

Empirical Analysis Statistics

Using these methods, the project team constructed a set of statistical tests to examine precision,
bias, and relatedness of indicators for all accepted hospital-level indicators, and precision and bias for all
accepted area-level and experimental indicators. Each of the key statistical test results was summarized
and explained in the overview section of the companion HCUP Quality Indicator report.128 Tables B-1
through B-3 provide a summary of the statistical analyses and their interpretation.
Table B-1. Precision Tests

Measure Statistic/Adjustments Interpretation

Precision. Is most of the variation in an indicator at the level of the hospital? Do smoothed
estimates of quality lead to more precise measures?
a. Observed Hospital-Level Unadjusted Risk adjustment can either
variation in Standard Deviation increase or decrease observed
Age-gender adjusted
indicator variation. If increase, then
Hospital -Level Skew
Modified DRG differences in patient
Statistic
adjusted characteristics mask provider
differences. If decrease, then
Modified AHRQ differences in patient
comorbidity adjusted characteristics account for
provider differences.
b. MSX methods Signal Standard Reliability adjusted Estimates what percentage of
Deviation the observed variation between
hospitals reflects systematic
Signal Share
differences versus random
Signal Ratio noise. Signal share is a measure
of how much of the total
variation (patient and provider) is
potentially subject to hospital
control.

128
Davies et al., 2001.

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Table B-2. Bias Tests

Measure Statistic Interpretation

Bias. Does risk adjustment change our assessment of relative hospital performance, after
accounting for reliability? Is the impact greatest among the best or worst performers, or
overall? What is the magnitude of the change in performance?
MSX methods: Spearman Rank Correlation Coefficient Risk adjustment matters to
unadjusted vs. (before and after risk adjustment) the extent that it alters the
age, sex, assessment of relative
modified DRG, hospital performance. This
comorbidity risk test determines the impact
adjustment overall.
Average absolute value of change relative to This test determines whether
mean (after risk adjustment) the absolute change in
performance was large or
small relative to the overall
mean.
Percentage of the top 10% of hospitals that This test measures the
remains the same (after risk adjustment) impact at the highest rates (in
general, the worse
performers).
Percentage of the bottom 10% of hospitals This test measures the
that remains the same (after risk adjustment) impact at the lowest rates (in
general, the better
performers).
Percentage of hospitals that move more than This test determines the
two deciles in rank (up or down) (after risk magnitude of the relative
adjustment) changes.

Table B-3. Relatedness Tests

Measure Statistic Interpretation

3. Relatedness of indicators. Is the indicator related to other indicators in a way that makes
clinical sense? Do methods that remove noise and bias make the relationship clearer?
a. Correlation of Spearman correlation coefficient Are indicators correlated with
indicator with other indicators in the
other indicators direction one might expect?
b. Factor loadings Factor loadings, based on Spearman Do indicators load on factors
of indicator correlation, Principal Component Analysis with other indicators that one
might expect?

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