Hospital Harm - Acute Kidney Injury 4.0.000

The measure assesses the proportion of inpatient hospitalizations for patients age 18 and older who have an acute kidney injury (AKI) stage 2 or greater that occurred during the encounter

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This material includes SNOMED Clinical Terms (R) (SNOMED CT [R]) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO). All rights reserved. SNOMED CT (R), was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material contains content from LOINC (http://loinc.org). LOINC is copyright (C) Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC (R) is a registered United States trademark of Regenstrief Institute, Inc.

This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

First vital signs since the encounter start:

Heart Rate: {Beats}/min
Respiratory Rate: {Breaths}/min
Systolic Blood Pressure: mm[Hg]
Temperature: Cel [degF]

Encounter diagnoses for:

Cancer (leukemia, lymphoma, or metastatic cancer)
Diabetes (with and without complications)
Heart failure present on admission (POA)
Hypertension (complicated and uncomplicated)
Obesity

Additional variables used for risk adjustment:

Sex
Age
Encounter length of stay (days)
Estimated glomerular filtration rate (eGFR) calculated using the index serum creatinine, patient sex, and age-based formula

All encounter diagnoses along with their POA indicators are being collected for future re-evaluation of the risk adjustment model.

Please see the Hospital Harm - Acute Kidney Injury Risk Adjustment Methodology Report on the eCQI Resource Center: https://ecqi.healthit.gov/.

This measure focuses on stage 2 or greater AKI as an outcome in the hospital inpatient setting. The incidence of AKI in general hospitalized patients is 10–20%, and among critically ill patients, the incidence of AKI has been reported as high as 45–50%; in cardiac surgery patients it ranges from 30–50% (Thongprayoon et al., 2020). Less severe AKI and AKI requiring dialysis affect approximately 2,000 to 3,000 and 200 to 300 per million population per year, respectively. AKI may result in the need for dialysis and is associated with an increased risk of mortality (Schwager et al., 2023; Wilson et al., 2013).

While not all instances of AKI are avoidable and may be due to natural progression of underlying illness or a complication of a necessary treatment, such as chemotherapy, a proportion of AKI cases are preventable and treatable. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest careful management of hemodynamic status, fluids, and vasoactive medications for the prevention of AKI (2012). Several studies identified through systematic literature searches developed or evaluated the effectiveness of AKI electronic alert systems (Schwager et al., 2023; Selby et al., 2012; Ahmed et al., 2015; Porter et al., 2014; Wilson et al., 2014; Kirkendall et al., 2014; Cho et al., 2012). These studies used data elements for defining AKI that were already present and populated in the electronic health record (EHR). For AKI diagnosis, all except two were limited to using serum creatinine levels, suggesting that this is the most reliable and consistently available electronic data element for defining AKI.

Serum creatinine is an accepted proxy for AKI (Ostermann et al., 2020; KDIGO, 2012). The measure uses an eGFR equation that measures serum creatinine or cystatin C and incorporates age, sex, and race to estimate measured GFR, which is recommended by the Task Force from the National Kidney Foundation and American Society of Nephrology (Inker et al., 2021; Diao et al., 2021; Delgado et al., 2021; Delgado et al., 2022). This functionality has been available to all laboratories in the United States (Delgado et al., 2021; Delgado et al., 2022) and has acceptable performance characteristics.

The KDIGO offers clinical practice guidelines for preventing and managing AKI:

FLUIDS 3.1.1: In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for acute kidney injury or with acute kidney injury. (Level 2, grade B)

VASOPRESSORS 3.1.2: We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for, acute kidney injury. (Level 1, grade C)

PROTOCOLIZED HEMODYNAMIC MANAGEMENT 3.1.3: We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of acute kidney injury in high-risk patients in the perioperative setting (2C) or in patients with septic shock. (Level 2, grade C)

KDIGO held a follow-up conference in April of 2019 to review key relevant literature published since the 2012 KDIGO clinical practice recommendations (Ostermann et al., 2020). The effectiveness of the 2012 KDIGO recommendations in preventing AKI was also noted to have been confirmed in small single-center randomized controlled trials (RCTs), such as the Prevention of AKI (PrevAKI) and the Biomarker Guided Intervention for Prevention of AKI (BigpAK) studies (Meersch et al., 2017; Göcze et al., 2018). In addition, results of RCTs have provided new data relevant to several facets of preventing and managing AKI, including early resuscitation, fluid therapy, prevention of contrast-associated AKI, and timing of acute renal replacement therapy (RRT) (Kellum et al., 2016; Nijssen et al., 2017; Self et al., 2018; Zarbock et al, 2016; Gaudry et al., 2016; Barbar et al., 2018).

Decreased score indicates improvement

Reference Type: Citation

Reference Text:

Ahmed, A., Vairavan, S., Akhoundi, A., Wilson, G., Chiofolo, C., Chbat, N., & Kashani, K. (2015). Development and validation of electronic surveillance tool for acute kidney injury: A retrospective analysis. Journal of Critical Care, 30(5), 988-993. https://doi.org/10.1016/j.jcrc.2015.05.007

Reference Type: Citation

Reference Text:

Barbar, S.D., Clere-Jehl, R., Bourredjem, A., Hernu, R., Montin,i F., Bruyère, R., Lebert, C., Bohé, J., Badie, J., Erald,i J.P., Rigaud, J.P., Levy, B., Siam,i S., Louis, G., Bouadma, L., Constantin, J.M., Mercier, E., Klouche, K., du Cheyron, D., ... Quenot, J.P., IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network (2018). Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. New England Journal of Medicine, 379(15), 1431–1442. https://doi.org/10.1056/NEJMoa1803213

Reference Type: Citation

Reference Text:

Cho, A., Lee, J.E., Yoon, J.Y., Jang, H.R., Huh, W., Kim, Y.G., & Oh, H.Y. (2012). Effect of an electronic alert on risk of contrast-induced acute kidney injury in hospitalized patients undergoing computed tomography. American Journal of Kidney Diseases, 60(1), 74-81. http://dx.doi.org/10.1053/j.ajkd.2012.02.331

Reference Type: Citation

Reference Text:

Delgado, C., Baweja, M., Crews, D.C., Eneanya, N.D., Gadegbeku, C.A., Inker, L.A., Mendu, M L., Miller, W.G., Moxey-Mims, M.M., Roberts, G.V., St Peter, W.L., Warfield, C., & Powe, N.R. (2021). A unifying approach for GFR estimation: Recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. Journal of the American Society of Nephrology, 32(12), 2994–3015. https://doi.org/10.1681/ASN.2021070988

Reference Type: Citation

Reference Text:

Delgado, C., Baweja, M., Crews, D.C., Eneanya, N.D., Gadegbeku, C.A., Inker, L.A., Mendu, M.L., Miller, W.G., Moxey-Mims, M.M., Roberts, G.V., St Peter, W.L., Warfield, C., & Powe, N.R. (2022). A unifying approach for GFR estimation: Recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. American Journal of Kidney Diseases, 79(2), 268–288.e1. https://doi.org/10.1053/j.ajkd.2021.08.003

Reference Type: Citation

Reference Text:

Diao, J.A., Inker, L.A., Levey, A.S., Tighiouart, H., Powe, N.R., & Manrai, A.K. (2021). In search of a better equation –Performance and equity in estimates of kidney function. New England Journal of Medicine, 384(5), 396–399. https://doi.org/10.1056/NEJMp2028243

Reference Type: Citation

Reference Text:

Gaudry, S., Hajage, D., Schortgen, F., Martin-Lefevre, L., Pons, B., Boulet, E., Boyer, A., Chevrel, G., Lerolle, N., Carpentier, D., de Prost, N., Lautrette, A., Bretagnol, A., Mayaux, J., Nseir, S., Megarbane, B., Thirion, M., Forel, J.M., Maize,l J., ... Dreyfuss, D. (2016). Initiation strategies for renal-replacement therapy in the intensive care unit. New England Journal of Medicine, 375(2), 122–133. https://doi.org/10.1056/NEJMoa1603017

Reference Type: Citation

Reference Text:

Göcze, I., Jauch, D., Götz, M., Kennedy, P., Jung, B., Zeman, F., Gnewuch, C., Graf, B. M., Gnann, W., Banas, B., Bein, T., Schlitt, H. J., & Bergler, T. (2018). Biomarker-guided intervention to prevent acute kidney injury after major surgery: The prospective randomized BigpAK study. Annals of Surgery, 267(6), 1013–1020. https://doi.org/10.1097/SLA.0000000000002485

Reference Type: Citation

Reference Text:

Inker, L.A., Eneanya, N.D., Coresh, J., Tighiouart, H., Wang, D., Sang, Y., Crews, D.C., Doria, A., Estrella, M.M., Froissart, M., Grams, M.E., Greene, T., Grubb, A., Gudnason, V., Gutiérrez, O.M., Kalil, R., Karger, A.B., Mauer, M., Navis, G., ... Levey, A.S. (2021). New creatinine- and cystatin c-based equations to estimate GFR without race. New England Journal of Medicine, 385(19), 1737–1749. https://doi.org/10.1056/NEJMoa2102953

Reference Type: Citation

Reference Text:

Kellum, J.A., Chawla, L.S., Keener, C., Singbartl, K., Palevsky, P.M., Pike, F.L., Yealy, D.M., Huang, D.T., Angus, D.C., & ProCESS and ProGReSS-AKI Investigators. (2016). The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock. American Journal of Respiratory and Critical Care Medicine, 193(3), 281–287. https://doi.org/10.1164/rccm.201505-0995OC

Reference Type: Citation

Reference Text:

Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. (2012). KDIGO 2012 clinical practice guideline for acute kidney injury. Kidney International, Supplements, 2(1), 1–141. https://doi.org/10.1038/kisup.2012.2

Reference Type: Citation

Reference Text:

Kirkendall, E.S., Spires, W.L., Mottes, T.A., Schaffzin, J.K., Barclay, C., & Goldstein, S.L. (2014). Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm. Applied Clinical Informatics, 5(2), 313-333. https://doi.org/10.4338/ACI-2013-12-RA-0102

Reference Type: Citation

Reference Text:

Lameire, N.H., Levin, A., Kellum, J.A., Cheung, M., Jadoul, M., Winkelmayer, W.C., Stevens, P.E., & Conference Participants. (2021). Harmonizing acute and chronic kidney disease definition and classification: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney International, 100(3), 516–526. https://doi.org/10.1016/j.kint.2021.06.028

Reference Type: Citation

Reference Text:

Lopes, J.A., & Jorge, S. (2013). The RIFLE and AKIN classifications for acute kidney injury: A critical and comprehensive review. Clinical Kidney Journal, 6(1), 8-14. https://doi.org/10.1093/ckj/sfs160

Reference Type: Citation

Reference Text:

Meersch, M., Schmidt, C., Hoffmeier, A., Van Aken, H., Wempe, C., Gerss, J., & Zarbock, A. (2017). Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: The PrevAKI randomized controlled trial. Intensive Care Medicine, 43(11), 1551–1561. https://doi.org/10.1007/s00134-016-4670-3

Reference Type: Citation

Reference Text: Nijssen, E.C., Rennenberg, R.J., Nelemans, P.J., Essers, B.A., Janssen, M.M., Vermeeren, M.A., Ommen, V.V., & Wildberger, J.E. (2017). Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): A prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet, 389(10076), 1312–1322. https://doi.org/10.1016/S0140-6736(17)30057-0

Reference Type: Citation

Reference Text:

Ostermann, M., Bellomo, R., Burdmann, E.A., Doi, K., Endre, Z.H., Goldstein, S.L., Kane-Gill, S.L., Liu, K.D., Prowle, J.R., Shaw, A.D., Srisawat, N., Cheung, M., Jadoul, M., Winkelmayer, W.C., Kellum, J.A., & Conference Participants. (2020). Controversies in acute kidney injury: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney international, 98(2), 294–309. https://doi.org/10.1016/j.kint.2020.04.020

Reference Type: Citation

Reference Text:

Porter, C.J., Juurlink, I., Bisset, L.H., Bavakunji, R., Mehta, R.L., & Devonald, M.A. (2014). A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital. Nephrology Dialysis Transplantation, 29(10), 1888-1893. https://doi.org/10.1093/ndt/gfu082

Reference Type: Citation

Reference Text:

Schwager, E., Ghosh, E., Eshelman, L., Pasupathy, K.S., Barreto, E.F., & Kashani, K. (2023). Accurate and interpretable prediction of ICU-acquired AKI. Journal of Critical Care, 75, 154278. https://doi.org/10.1016/j.jcrc.2023.154278

Reference Type: Citation

Reference Text:

Selby, N.M., Crowley, L., Fluck, R.J., McIntyre, C.W., Monaghan, J., Lawson, N., & Kolhe, N.V. (2012). Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. Clinical Journal of the American Society of Nephrology, 7(4), 533-540. https://doi.org/10.2215/cjn.08970911

Reference Type: Citation

Reference Text:

Self, W.H., Semler, M.W., Wanderer, J.P., Wang, L., Byrne, D.W., Collins, S.P., Slovis, C.M., Lindsell, C.J., Ehrenfeld, J.M., Siew, E.D., Shaw, A.D., Bernard, G.R., Rice, T.W., & SALT-ED Investigators. (2018). Balanced crystalloids versus saline in noncritically ill adults. New England Journal of Medicine, 378(9), 819–828. https://doi.org/10.1056/NEJMoa1711586

Reference Type: Citation

Reference Text:

Thongprayoon, C., Hansrivijit, P., Kovvuru, K., Kanduri, S.R., Torres-Ortiz, A., Acharya, P., Gonzalez-Suarez, M.L., Kaewput, W., Bathini, T., & Cheungpasitporn, W. (2020). Diagnostics, risk factors, treatment and outcomes of acute kidney injury in a new paradigm. Journal of Clinical Medicine, 9(4), 1104. https://doi.org/10.3390/jcm9041104

Reference Type: Citation

Reference Text:

Wilson, F. P., Yang, W., & Feldman, H.I. (2013). Predictors of death and dialysis in severe AKI: The UPHS-AKI cohort. Clinical Journal of the American Society of Nephrology, 8(4), 527-537. https://doi.org/10.2215/cjn.06450612

Reference Type: Citation

Reference Text:

Wilson, F.P., Reese, P.P., Shashaty, M.G., Ellenberg, S.S., Gitelman, Y., Bansal, A.D., & Fuchs, B. (2014). A trial of in-hospital, electronic alerts for acute kidney injury: Design and rationale. Clinical Trials, 11(5), 521-529. https://doi.org/10.1177/1740774514542619

Reference Type: Citation

Reference Text:

Zarbock, A., Kellum, J.A., Schmidt, C., Van Aken, H., Wempe, C., Pavenstädt, H., Boanta, A., Gerß, J., & Meersch, M. (2016). Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN randomized clinical trial. Journal of the American Medical Association, 315(20), 2190–2199. https://doi.org/10.1001/jama.2016.5828

Inpatient hospitalizations: Includes time in the emergency department and/or in observation status when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less.

AKI stage 2 or greater is defined as a substantial increase in serum creatinine value, or by the initiation of kidney dialysis (continuous renal replacement therapy (CRRT), hemodialysis, or peritoneal dialysis).

The numerator harm, AKI stage 2 or greater, is defined as an increase in serum creatinine at least 2 times higher than the lowest serum creatinine value. The increased value must be greater than the highest sex-specific normal value for serum creatinine. The following steps are performed to determine if these criteria for AKI are met:

To identify AKI stage 2 or greater, evaluate if any serum creatinine value obtained between 48 hours after the start of the hospitalization and either discharge or 30 days after the start of the hospitalization, whichever is sooner, is at least 1.5 times higher than the lowest value obtained within the prior 7 days. If yes, then:

Evaluate if the increased serum creatinine is greater than the highest sex-specific normal value for serum creatinine. If yes, then:
To stage AKI, evaluate if any serum creatinine value obtained between 48 hours after the start of the hospitalization and either discharge or 30 days after the start of the hospitalization, whichever is sooner, is at least 2 times higher than the lowest value obtained within the prior 7 days. If yes, then:

Evaluate if the increased serum creatinine value is greater than the highest sex-specific normal value for serum creatinine. If yes, then an AKI stage 2 or greater has been identified.

The highest normal serum creatinine value for females is defined as 1.02 mg/dL. The highest normal serum creatinine value for males is defined as 1.18 mg/dL.

The eGFR values are calculated using the CKD-EPI Creatinine Equation, recommended by the National Kidney Foundation (Delgado et al., 2022). This is a sex-specific, race-neutral formula.

The CKD-EPI Creatinine Equation used for females: 142 x [min((Serum Creatinine)/0.7,1)] raised to the power of (-0.241) x max [((Serum Creatinine)/0.7,1) raised to the power of (-1.200)] x [0.9938] raised to the power of Age x 1.012.

The CKD-EPI Creatinine Equation used for males: 142 x [min((Serum Creatinine)/0.9,1)] raised to the power of (-0.302) x max [((Serum Creatinine)/0.9,1) raised to the power of (-1.200)] x [0.9938] raised to the power of Age.

The "index" serum creatinine is defined as the lowest serum creatinine value within the first 24 hours of encounter start. If there are no serum creatinine values within the first 24 hours, then the index is the first serum creatinine value within the first 48 hours of the encounter start. This serum creatinine value is used to identify and exclude patients with AKI at the start of the encounter.

The "index" eGFR is calculated using the "index" serum creatinine, patient sex, and patient age based on the CKD-EPI Creatinine Equation.

"Initiation" of kidney dialysis (CRRT, hemodialysis, and peritoneal) during hospitalization is defined as documentation that kidney dialysis (CRRT, hemodialysis, or peritoneal) was started during the encounter.

In addition to clinical electronic health record data, this measure uses Present on Admission (POA) indicators (e.g., POA = U) as found in billing/claims system within the measure criteria.

The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission.

A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission)
A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission)
A POA Indicator of W = clinically undetermined
A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission

Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.

A patient characteristic of male or female sex is required as part of the initial population criteria, as sex is crucial to this measure. For example:

The eGFR estimating equation that is used to identify AKI is sex-specific; and
The reference ranges for the serum creatinine value are sex-specific, which matters because the serum creatinine must rise to a sex-specific abnormal value to be flagged as AKI.

Exclude encounters that do not have at least two serum creatine values within 48 hours of arrival. Two values are needed within this timeframe to determine if the patient has AKI or moderate-to-severe renal dysfunction on arrival.

For encounters for patients without harm, as identified by 2 times increase in serum creatinine, query for initiation of renal dialysis during hospitalization, defined by the start of dialysis occurring during the encounter.

If dialysis starts more than 48 hours after the start of the encounter, this meets numerator criteria.
If dialysis starts 48 hours or less after the start of the encounter, this meets denominator exclusion criteria.

Encounters for patients with an increase in serum creatinine value of at least 0.3 mg/dL between the index serum creatinine and any subsequent serum creatinine taken within 48 hours of the encounter start are excluded. Due to the variability of decimal precision within programming languages and calculation tools, the value of >=0.3 is expressed in the logic as >0.299.

Note the measure is currently confined to using mg/dL as the unit of measurement for creatinine and mL/min as the unit of measurement for eGFR results.

When reporting the first body temperature for risk adjustment, values from either Celsius or Fahrenheit readings are acceptable to report but Celsius readings are preferred.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Inpatient hospitalizations that end during the measurement period for patients 18 years of age or older without an obstetrical or pregnancy-related condition, with a length of stay of 48 hours or longer, and who had at least one serum creatinine value after 48 hours from the start of the hospitalization

Equals Initial Population

Inpatient hospitalizations for patients with an increase in serum creatinine value of at least 0.3 mg/dL between the index serum creatinine and a subsequent serum creatinine taken within 48 hours of the encounter start.

Inpatient hospitalizations for patients with the index eGFR value of <60 mL/min within 48 hours of the encounter start.

Inpatient hospitalizations for patients who have less than two serum creatinine results within the first 48 hours of the encounter start.

Inpatient hospitalizations for patients who have kidney dialysis (CRRT, hemodialysis, or peritoneal dialysis) initiated 48 hours or less after the encounter start, and who do not have evidence of a 2 times increase in serum creatinine.

Inpatient hospitalizations for patients with at least one specified diagnosis present on admission during the encounter that puts them at extremely high risk for AKI:

Hemolytic Uremic Syndrome (HUS)
Large Body Surface Area (BSA) Burns
Traumatic Avulsion of Kidney
Rapidly Progressive Nephritic Syndrome
Thrombotic Thrombocytopenic Purpura
Out of Hospital Cardiac Arrest (OHCA)

Inpatient hospitalizations for patients who have at least one specified procedure that starts during the encounter that puts them at extremely high risk for AKI:

Extracorporeal membrane oxygenation (ECMO)
Intra-Aortic Balloon Pump
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Nephrectomy

Inpatient hospitalizations for patients who develop AKI stage 2 or greater during the encounter, as evidenced by:

A subsequent increase in serum creatinine value at least 2 times higher than the lowest serum creatinine value, and the increased value is greater than the highest sex-specific normal value for serum creatinine.

Or:

Kidney dialysis (CRRT, hemodialysis, or peritoneal dialysis) initiated more than 48 hours after the start of the encounter. Evidence of a 2 times increase in serum creatinine is not required.

Only one harm is counted per encounter.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Initial Population

  "Encounters With Creatinine And Without Obstetrical Conditions"

- Denominator
  - "Initial Population"

Denominator Exclusions

  "Encounters With 0.3 mg dL Or More Increase In Creatinine Within First 48 Hours"
    union "Encounters With Index eGFR Less Than 60 Within First 48 Hours"
    union "Encounters With Less Than 2 Creatinine Results Within First 48 Hours"
    union "Encounters With Kidney Dialysis Started 48 Hours Or Less After Arrival Without High Creatinine"
    union "Encounters With High Risk Diagnosis For AKI"
    union "Encounters With High Risk Procedures For AKI"

Numerator

  "Encounters With 2 Times Serum Creatinine Increase" 
    union "Encounters With Kidney Dialysis Started More Than 48 Hours After Arrival Without High Creatinine"

- Numerator Exclusions
  - None

- Denominator Exceptions
  - None

- Stratification
  - None

Denominator
- - "Initial Population"

Denominator Exclusion

  "Encounters With 0.3 mg dL Or More Increase In Creatinine Within First 48 Hours"
    union "Encounters With Index eGFR Less Than 60 Within First 48 Hours"
    union "Encounters With Less Than 2 Creatinine Results Within First 48 Hours"
    union "Encounters With Kidney Dialysis Started 48 Hours Or Less After Arrival Without High Creatinine"
    union "Encounters With High Risk Diagnosis For AKI"
    union "Encounters With High Risk Procedures For AKI"

Encounters With 0.3 mg dL Or More Increase In Creatinine Within First 48 Hours

"Increase Of 0.3 Or More Using Lowest Creatinine Within 24 Hours" union
"Increase Of 0.3 Or More Using First Creatinine Within First 48 Hours"

Encounters With 1.5 Times Serum Creatinine Increase

  from
      "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter,
      ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTest
    let 
      LowestCreatinineTestWithin7DaysPrior: "LowestSerumCreatinineWithin7DaysPrior"(QualifyingEncounter, CreatinineTest),
      CreatinineTestTime: Global."EarliestOf" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod ),
      HospitalWithObservation: Global."HospitalizationWithObservation" (QualifyingEncounter)
    where CreatinineTest.result.value >= LowestCreatinineTestWithin7DaysPrior * 1.5
      and CreatinineTest.result.value > "Serum Creatinine Normal"
      and CreatinineTestTime during Interval[start of HospitalWithObservation + 48 hours, start of HospitalWithObservation + 30 days]
      and CreatinineTestTime during HospitalWithObservation
    return QualifyingEncounter

Encounters With 2 Times Serum Creatinine Increase

  from 
      "Encounters With 1.5 Times Serum Creatinine Increase" EncounterWithHighCreatinine,
      ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTest
    let 
      LowestCreatinineTestPrior: "LowestSerumCreatinineWithin7DaysPrior"(EncounterWithHighCreatinine, CreatinineTest),
      CreatinineTestTime: Global."EarliestOf" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod ),
      HospitalWithObservation: Global."HospitalizationWithObservation" ( EncounterWithHighCreatinine )
    where CreatinineTest.result.value >= LowestCreatinineTestPrior * 2.0
      and CreatinineTest.result.value > "Serum Creatinine Normal"
      and CreatinineTestTime during Interval[start of HospitalWithObservation + 48 hours, start of HospitalWithObservation + 30 days]
      and CreatinineTestTime during HospitalWithObservation
    return EncounterWithHighCreatinine

Encounters With Age 18 And Length Of Stay 48 Hours Or More And Male Or Female Sex

  ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
    where InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
      and AgeInYearsAt(date from start of InpatientEncounter.relevantPeriod) >= 18
      and duration in hours of Global."HospitalizationWithObservation" ( InpatientEncounter ) >= 48
      and exists (
        ( ["Patient Characteristic Sex": "Female (finding)"] )
        union ( ["Patient Characteristic Sex": "Male (finding)"] )
      )

Encounters With Creatinine And Without Obstetrical Conditions

  "Inpatient Encounters With Creatinine" EncounterWithCreatinine
    where not exists ( EncounterWithCreatinine.diagnoses EncounterDiagnoses
        where EncounterDiagnoses.code in "Obstetrical or Pregnancy Related Conditions"
    )

Encounters With High Risk Diagnosis For AKI

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where exists ( QualifyingEncounter.diagnoses HighRiskforAKI
        where HighRiskforAKI.code in "High Risk Diagnosis for AKI"
          and HighRiskforAKI.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
    )
      and QualifyingEncounter.relevantPeriod during Global."HospitalizationWithObservation" ( QualifyingEncounter )

Encounters With High Risk Procedures For AKI

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    with ["Procedure, Performed": "High Risk Procedures for AKI"] HighRiskProcedures
      such that Global."NormalizeInterval" ( HighRiskProcedures.relevantDatetime, HighRiskProcedures.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter )

Encounters With Index eGFR Less Than 60 Within First 48 Hours

  "Male Encounters With eGFR Less Than 60"
    union "Female Encounters With eGFR Less Than 60"

Encounters With Kidney Dialysis Started 48 Hours Or Less After Arrival

  from
    ["Procedure, Performed": "Hospital Based Dialysis Services"] Dialysis,
    "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where Global."NormalizeInterval" ( Dialysis.relevantDatetime, Dialysis.relevantPeriod ) starts during Interval[start of Global."HospitalizationWithObservation" ( QualifyingEncounter ), start of Global."HospitalizationWithObservation" ( QualifyingEncounter ) + 48 hours]
      and Global."NormalizeInterval" ( Dialysis.relevantDatetime, Dialysis.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter )
    return QualifyingEncounter

Encounters With Kidney Dialysis Started 48 Hours Or Less After Arrival Without High Creatinine

  "Encounters With Kidney Dialysis Started 48 Hours Or Less After Arrival" EncounterWithKidneyDialysis48HoursOrAfter
    where not ( exists ( "Encounters With 2 Times Serum Creatinine Increase"  EncounterWithHighCreatinine
         where ( EncounterWithHighCreatinine.relevantPeriod includes EncounterWithKidneyDialysis48HoursOrAfter.relevantPeriod )
      )
   )

Encounters With Kidney Dialysis Started More Than 48 Hours After Arrival

  from
    ["Procedure, Performed": "Hospital Based Dialysis Services"] Dialysis,
    "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where Global."NormalizeInterval" ( Dialysis.relevantDatetime, Dialysis.relevantPeriod ) starts during Interval(start of Global."HospitalizationWithObservation" ( QualifyingEncounter ) + 48 hours, end of Global."HospitalizationWithObservation" ( QualifyingEncounter )]
      and Global."NormalizeInterval" ( Dialysis.relevantDatetime, Dialysis.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter )
    return QualifyingEncounter

Encounters With Kidney Dialysis Started More Than 48 Hours After Arrival Without High Creatinine

  "Encounters With Kidney Dialysis Started More Than 48 Hours After Arrival" EncounterWithDialysisAfter48Hours
    where not ( exists ( "Encounters With 2 Times Serum Creatinine Increase" EncounterWithHighCreatinine
          where ( EncounterWithHighCreatinine.relevantPeriod includes EncounterWithDialysisAfter48Hours.relevantPeriod )
      )
    )

Encounters With Less Than 2 Creatinine Results Within First 48 Hours

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where ( Count("CreatinineLabTestwithResultwithinFirst48Hours"(QualifyingEncounter)) < 2 )

Female Encounters With eGFR Less Than 60

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where "FemaleeGFR"(QualifyingEncounter) is not null
      and "FemaleeGFR"(QualifyingEncounter) as Decimal < 60

Increase Of 0.3 Or More Using First Creatinine Within First 48 Hours

  from
    "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter,
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] IndexCreatinineLabResult,
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] SubsequentCreatinineLabResult
    let IndexCreatinineLabResultTime: Global."EarliestOf" ( IndexCreatinineLabResult.relevantDatetime, IndexCreatinineLabResult.relevantPeriod ),
    SubsequentCreatinineLabResultTime: Global."EarliestOf" ( SubsequentCreatinineLabResult.relevantDatetime, SubsequentCreatinineLabResult.relevantPeriod ),
    HospitalWithObservation: Global."HospitalizationWithObservation" ( QualifyingEncounter )
    where ( SubsequentCreatinineLabResult.result.value ) - ( IndexCreatinineLabResult.result.value ) > 0.299
      and IndexCreatinineLabResult.result.value = "EarliestSerumCreatinine"(QualifyingEncounter)
      and IndexCreatinineLabResultTime during Interval[SubsequentCreatinineLabResultTime - 48 hours, SubsequentCreatinineLabResultTime]
      and IndexCreatinineLabResultTime during HospitalWithObservation
      and SubsequentCreatinineLabResultTime during Interval[start of HospitalWithObservation, start of HospitalWithObservation + 48 hours]
      and SubsequentCreatinineLabResultTime during HospitalWithObservation
      and IndexCreatinineLabResultTime during Interval[start of HospitalWithObservation, start of HospitalWithObservation + 48 hours]
      and SubsequentCreatinineLabResultTime during Interval[start of HospitalWithObservation, start of HospitalWithObservation + 48 hours]
      and IndexCreatinineLabResult.id != SubsequentCreatinineLabResult.id
      and "LowestSerumCreatinineIn24Hours"(QualifyingEncounter) is null
    return QualifyingEncounter

Increase Of 0.3 Or More Using Lowest Creatinine Within 24 Hours

  from
    "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter,
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] IndexCreatinineLabResult,
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] SubsequentCreatinineLabResult
    let IndexCreatinineLabResultTime: Global."EarliestOf" ( IndexCreatinineLabResult.relevantDatetime, IndexCreatinineLabResult.relevantPeriod ),
    SubsequentCreatinineLabResultTime: Global."EarliestOf" ( SubsequentCreatinineLabResult.relevantDatetime, SubsequentCreatinineLabResult.relevantPeriod ),
    HospitalWithObservation: Global."HospitalizationWithObservation" ( QualifyingEncounter )
    where ( SubsequentCreatinineLabResult.result.value ) - ( IndexCreatinineLabResult.result.value ) > 0.299
      and IndexCreatinineLabResult.result.value = "LowestSerumCreatinineIn24Hours"(QualifyingEncounter).value
      and IndexCreatinineLabResultTime during Interval[start of HospitalWithObservation, SubsequentCreatinineLabResultTime]
      and IndexCreatinineLabResultTime during HospitalWithObservation
      and IndexCreatinineLabResultTime during Interval[start of HospitalWithObservation, start of HospitalWithObservation + 24 hours]
      and SubsequentCreatinineLabResultTime during HospitalWithObservation
      and SubsequentCreatinineLabResultTime during Interval[start of HospitalWithObservation, start of HospitalWithObservation + 48 hours]
      and IndexCreatinineLabResult.id != SubsequentCreatinineLabResult.id
    return QualifyingEncounter

Initial Population

  "Encounters With Creatinine And Without Obstetrical Conditions"

Inpatient Encounters With Creatinine

  from
    "Encounters With Age 18 And Length Of Stay 48 Hours Or More And Male Or Female Sex" Encounter48Hours,
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTest
    let HospitalizationPeriod: Global."HospitalizationWithObservation" ( Encounter48Hours ),
    CreatinineTestTime: Global."EarliestOf" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod )
    where CreatinineTest.result is not null
      and CreatinineTestTime during Interval[start of HospitalizationPeriod + 48 hours, end of HospitalizationPeriod]
    return Encounter48Hours

Male Encounters With eGFR Less Than 60

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    where "MaleeGFR"(QualifyingEncounter) is not null
      and "MaleeGFR"(QualifyingEncounter) as Decimal < 60

Numerator

  "Encounters With 2 Times Serum Creatinine Increase" 
    union "Encounters With Kidney Dialysis Started More Than 48 Hours After Arrival Without High Creatinine"

Risk Variable Age

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      age: AgeInYearsAt(date from start of QualifyingEncounter.relevantPeriod)
    }

Risk Variable All Encounter Diagnoses With POA Indication

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      diagnosiscode: QualifyingEncounter.diagnoses.code,
      POA: QualifyingEncounter.diagnoses.presentOnAdmissionIndicator
    }

Risk Variable Cancer LLM

   flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Cancer LLM ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

Risk Variable Diabetes

   flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Diabetes ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

Risk Variable Encounter Length Of Stay

from "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
return Tuple {
    encounterLOS: Global."LengthInDays" ( Global."HospitalizationWithObservation" ( QualifyingEncounter)),
    encounterId: QualifyingEncounter.id,
    encounterPeriod: QualifyingEncounter.relevantPeriod
}

Risk Variable Estimated Glomerular Filtration Rate For Females

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      eGFR: "FemaleeGFR"(QualifyingEncounter)
    }

Risk Variable Estimated Glomerular Filtration Rate For Males

  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      eGFR: "MaleeGFR"(QualifyingEncounter)
    }

Risk Variable First Heart Rate In Encounter

    // Qualifying Encounter: Report heart rate as {Beats}/min
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstHeartRate: "FirstHeartRate"(QualifyingEncounter)
    }

Risk Variable First Respiratory Rate In Encounter

    // Qualifying Encounter: Report respiratory rate as {Breaths}/min
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstRespiratoryRate: "FirstRespiratoryRate"(QualifyingEncounter)
    }

Risk Variable First Systolic Blood Pressure In Encounter

   // Qualifying Encounter: Report systolic blood pressure rate as mm[Hg]
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstSystolicBP: "FirstSystolicBloodPressure"(QualifyingEncounter)
    }

Risk Variable First Temperature In Encounter

   // Qualifying Encounter: Report temperature as Cel or [deg F]
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstTemperature: "FirstBodyTemperature"(QualifyingEncounter)
    }

Risk Variable Heart Failure

   flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Heart Failure ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

Risk Variable Hypertension

   flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Hypertension ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

Risk Variable Obesity

   flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Obesity ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

Risk Variable Sex

 from
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter,
  "SDE Sex" Sex
    return Tuple {
      encounterId: QualifyingEncounter.id,
      S: Sex.code
    }

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Serum Creatinine Normal

  if exists ( ["Patient Characteristic Sex": "Female (finding)"] ) then 1.02 
  else 1.18

CreatinineLabTestwithResultwithinFirst48Hours(QualifyingEncounter "Encounter, Performed")

  from
    ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTest
    where CreatinineTest.result is not null
      and Global."EarliestOf" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod ) during Interval[start of Global."HospitalizationWithObservation" ( QualifyingEncounter ), start of Global."HospitalizationWithObservation" ( QualifyingEncounter ) + 48 hours]
      and Global."EarliestOf" ( CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod ) during Global."HospitalizationWithObservation" ( QualifyingEncounter )
    return CreatinineTest

EarliestSerumCreatinine(QualifyingEncounter "Encounter, Performed")

  First("SerumCreatinineSequencebyTime"(QualifyingEncounter)).result.value

FemaleeGFR(QualifyingEncounter "Encounter, Performed")

  if exists ( ["Patient Characteristic Sex": "Female (finding)"] ) then ( 142 * Min({("IndexCreatinine"(QualifyingEncounter).value / 0.7), 1 }) ^ ( - 0.241 ) * Max({("IndexCreatinine"(QualifyingEncounter).value / 0.7), 1 }) ^ ( - 1.200 ) * 0.9938 ^ ( AgeInYearsAt(start of Global."HospitalizationWithObservation"(QualifyingEncounter)) ) * 1.012 ) 
    else null as Decimal

FirstBodyTemperature(QualifyingEncounter "Encounter, Performed")

  First(["Physical Exam, Performed": "Body temperature"] FirstTemperature
      where Global."EarliestOf"(FirstTemperature.relevantDatetime, FirstTemperature.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and FirstTemperature.result is not null
      sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
  ).result as Quantity

FirstHeartRate(QualifyingEncounter "Encounter, Performed")

  First(["Physical Exam, Performed": "Heart rate"] FirstHeartBeats
      where Global."EarliestOf"(FirstHeartBeats.relevantDatetime, FirstHeartBeats.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and FirstHeartBeats.result is not null
      sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
  ).result as Quantity

FirstRespiratoryRate(QualifyingEncounter "Encounter, Performed")

  First(["Physical Exam, Performed": "Respiratory rate"] FirstRespiration
      where Global."EarliestOf"(FirstRespiration.relevantDatetime, FirstRespiration.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and FirstRespiration.result is not null
      sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
  ).result as Quantity

FirstSerumCreatinineIn48Hours(QualifyingEncounter "Encounter, Performed")

  First(["Laboratory Test, Performed": "Creatinine Mass Per Volume"] FirstCreatinineTest
      where Global."EarliestOf"(FirstCreatinineTest.relevantDatetime, FirstCreatinineTest.relevantPeriod) during Interval[start of Global."HospitalizationWithObservation"(QualifyingEncounter), start of Global."HospitalizationWithObservation"(QualifyingEncounter) + 48 hours]
        and Global."EarliestOf"(FirstCreatinineTest.relevantDatetime, FirstCreatinineTest.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and FirstCreatinineTest.result is not null
        and "LowestSerumCreatinineIn24Hours"(QualifyingEncounter) is null
      sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
  ).result as Quantity

FirstSystolicBloodPressure(QualifyingEncounter "Encounter, Performed")

  First(["Physical Exam, Performed": "Systolic blood pressure"] FirstSystolic
      where Global."EarliestOf"(FirstSystolic.relevantDatetime, FirstSystolic.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and FirstSystolic.result is not null
      sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
  ).result as Quantity

Global.Earliest(period Interval<DateTime>)

  if ( HasStart(period)) then start of period 
    else 
  end of period

Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)
- - Earliest(NormalizeInterval(pointInTime, period))

Global.HasStart(period Interval<DateTime>)

  not ( start of period is null
      or start of period = minimum DateTime
  )

Global.HospitalizationWithObservation(Encounter "Encounter, Performed")

  Encounter Visit
  	let ObsVisit: Last(["Encounter, Performed": "Observation Services"] LastObs
  			where LastObs.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
  			sort by 
  			end of relevantPeriod
  	),
  	VisitStart: Coalesce(start of ObsVisit.relevantPeriod, start of Visit.relevantPeriod),
  	EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
  			where LastED.relevantPeriod ends 1 hour or less on or before VisitStart
  			sort by 
  			end of relevantPeriod
  	)
  	return Interval[Coalesce(start of EDVisit.relevantPeriod, VisitStart), 
  	end of Visit.relevantPeriod]

Global.LengthInDays(Value Interval<DateTime>)

  difference in days between start of Value and end of Value

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

  if pointInTime is not null then Interval[pointInTime, pointInTime]
    else if period is not null then period 
    else null as Interval<DateTime>

IndexCreatinine(QualifyingEncounter "Encounter, Performed")

  Coalesce("LowestSerumCreatinineIn24Hours"(QualifyingEncounter), "FirstSerumCreatinineIn48Hours"(QualifyingEncounter))

LowestSerumCreatinineIn24Hours(QualifyingEncounter "Encounter, Performed")

  Min(["Laboratory Test, Performed": "Creatinine Mass Per Volume"] LowCreatinine
      where Global."EarliestOf"(LowCreatinine.relevantDatetime, LowCreatinine.relevantPeriod) during Interval[start of Global."HospitalizationWithObservation"(QualifyingEncounter), start of Global."HospitalizationWithObservation"(QualifyingEncounter) + 24 hours]
        and Global."EarliestOf"(LowCreatinine.relevantDatetime, LowCreatinine.relevantPeriod) during Global."HospitalizationWithObservation"(QualifyingEncounter)
        and LowCreatinine.result is not null
      return LowCreatinine.result as Quantity
  )

LowestSerumCreatinineWithin7DaysPrior(QualifyingEncounter "Encounter, Performed", CreatinineTest "Laboratory Test, Performed")

  First(
    ("SerumCreatinineSequenceByQuantity"(QualifyingEncounter)) Test
      where Global."EarliestOf"(Test.relevantDatetime, Test.relevantPeriod) 7 days or less before Global."EarliestOf"(CreatinineTest.relevantDatetime, CreatinineTest.relevantPeriod)
  ).result.value

MaleeGFR(QualifyingEncounter "Encounter, Performed")

  if exists ( ["Patient Characteristic Sex": "Male (finding)"] ) then ( 142 * Min({("IndexCreatinine"(QualifyingEncounter).value / 0.9), 1 }) ^ ( - 0.302 ) * Max({("IndexCreatinine"(QualifyingEncounter).value / 0.9), 1 }) ^ ( - 1.200 ) * 0.9938 ^ ( AgeInYearsAt(start of Global."HospitalizationWithObservation"(QualifyingEncounter)) ) ) 
    else null as Decimal

SerumCreatinineSequenceByQuantity(Encounter "Encounter, Performed")

  ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTestByQuantity
    where Global."EarliestOf" ( CreatinineTestByQuantity.relevantDatetime, CreatinineTestByQuantity.relevantPeriod ) during Global."HospitalizationWithObservation" ( Encounter )
      and CreatinineTestByQuantity.result.value is not null
    sort by result.value

SerumCreatinineSequencebyTime(QualifyingEncounter "Encounter, Performed")

  ["Laboratory Test, Performed": "Creatinine Mass Per Volume"] CreatinineTestByTime
    where Global."EarliestOf" ( CreatinineTestByTime.relevantDatetime, CreatinineTestByTime.relevantPeriod ) during Global."HospitalizationWithObservation" ( QualifyingEncounter )
      and CreatinineTestByTime.result.value is not null
    sort by Global."EarliestOf" ( relevantDatetime, relevantPeriod )

code "Female (finding)" ("SNOMEDCT Code (248152002)")
code "Heart rate" ("LOINC Code (8867-4)")
code "Male (finding)" ("SNOMEDCT Code (248153007)")
code "Respiratory rate" ("LOINC Code (9279-1)")
code "Systolic blood pressure" ("LOINC Code (8480-6)")
valueset "Body temperature" (2.16.840.1.113762.1.4.1045.152)
valueset "Cancer LLM ICD10CM Elixhauser" (2.16.840.1.113762.1.4.1272.33)
valueset "Creatinine Mass Per Volume" (2.16.840.1.113762.1.4.1248.21)
valueset "Diabetes ICD10CM Elixhauser" (2.16.840.1.113762.1.4.1272.31)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Federal Administrative Sex" (2.16.840.1.113762.1.4.1021.121)
valueset "Heart Failure ICD10CM Elixhauser" (2.16.840.1.113762.1.4.1272.34)
valueset "High Risk Diagnosis for AKI" (2.16.840.1.113762.1.4.1248.12)
valueset "High Risk Procedures for AKI" (2.16.840.1.113762.1.4.1248.19)
valueset "Hospital Based Dialysis Services" (2.16.840.1.113762.1.4.1248.199)
valueset "Hypertension ICD10CM Elixhauser" (2.16.840.1.113762.1.4.1272.32)
valueset "Obesity ICD10CM Elixhauser" (2.16.840.1.113762.1.4.1272.35)
valueset "Observation Services" (2.16.840.1.113762.1.4.1111.143)
valueset "Obstetrical or Pregnancy Related Conditions" (2.16.840.1.113883.3.117.1.7.1.263)
valueset "Payer Type" (2.16.840.1.114222.4.11.3591)
valueset "Present on Admission or Clinically Undetermined" (2.16.840.1.113762.1.4.1147.197)
valueset "Race" (2.16.840.1.114222.4.11.836)

"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Observation Services" using "Observation Services (2.16.840.1.113762.1.4.1111.143)"
"Laboratory Test, Performed: Creatinine Mass Per Volume" using "Creatinine Mass Per Volume (2.16.840.1.113762.1.4.1248.21)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: Federal Administrative Sex" using "Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121)"
"Patient Characteristic Sex: Female (finding)" using "Female (finding) (SNOMEDCT Code 248152002)"
"Patient Characteristic Sex: Male (finding)" using "Male (finding) (SNOMEDCT Code 248153007)"
"Physical Exam, Performed: Body temperature" using "Body temperature (2.16.840.1.113762.1.4.1045.152)"
"Physical Exam, Performed: Heart rate" using "Heart rate (LOINC Code 8867-4)"
"Physical Exam, Performed: Respiratory rate" using "Respiratory rate (LOINC Code 9279-1)"
"Physical Exam, Performed: Systolic blood pressure" using "Systolic blood pressure (LOINC Code 8480-6)"
"Procedure, Performed: High Risk Procedures for AKI" using "High Risk Procedures for AKI (2.16.840.1.113762.1.4.1248.19)"
"Procedure, Performed: Hospital Based Dialysis Services" using "Hospital Based Dialysis Services (2.16.840.1.113762.1.4.1248.199)"

  ["Patient Characteristic Ethnicity": "Ethnicity"]

  ["Patient Characteristic Payer": "Payer Type"]

  ["Patient Characteristic Race": "Race"]

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

"Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      diagnosiscode: QualifyingEncounter.diagnoses.code,
      POA: QualifyingEncounter.diagnoses.presentOnAdmissionIndicator
    }

"Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      eGFR: "FemaleeGFR"(QualifyingEncounter)
    }

"Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      eGFR: "MaleeGFR"(QualifyingEncounter)
    }

// Qualifying Encounter: Report heart rate as {Beats}/min
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstHeartRate: "FirstHeartRate"(QualifyingEncounter)
    }

// Qualifying Encounter: Report respiratory rate as {Breaths}/min
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstRespiratoryRate: "FirstRespiratoryRate"(QualifyingEncounter)
    }

// Qualifying Encounter: Report systolic blood pressure rate as mm[Hg]
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstSystolicBP: "FirstSystolicBloodPressure"(QualifyingEncounter)
    }

// Qualifying Encounter: Report temperature as Cel or [deg F]
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      firstTemperature: "FirstBodyTemperature"(QualifyingEncounter)
    }

flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Diabetes ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Hypertension ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Cancer LLM ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Heart Failure ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

flatten( "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return(
        QualifyingEncounter.diagnoses EncounterDiagnosis
        where EncounterDiagnosis.code in "Obesity ICD10CM Elixhauser"
    return Tuple {
        encounterId: QualifyingEncounter.id,
        code: EncounterDiagnosis.code,
        poa: EncounterDiagnosis.presentOnAdmissionIndicator
     }
   ))

from
  "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter,
  "SDE Sex" Sex
    return Tuple {
      encounterId: QualifyingEncounter.id,
      S: Sex.code
    }

"Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
    return Tuple {
      encounterId: QualifyingEncounter.id,
      age: AgeInYearsAt(date from start of QualifyingEncounter.relevantPeriod)
    }

from "Encounters With Creatinine And Without Obstetrical Conditions" QualifyingEncounter
return Tuple {
    encounterLOS: Global."LengthInDays" ( Global."HospitalizationWithObservation" ( QualifyingEncounter)),
    encounterId: QualifyingEncounter.id,
    encounterPeriod: QualifyingEncounter.relevantPeriod
}

Hospital Harm - Acute Kidney Injury

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables