Severe Obstetric Complications | eCQI Resource Center

Measure Information	2023 Reporting Period
CMS eCQM ID	CMS1028v1
Short Name	PC-07
NQF Number	Not Applicable
Description	Patients with severe obstetric complications which occur during the inpatient delivery hospitalization.
Initial Population	Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period
Denominator	Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed
Denominator Exclusions	Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure
Numerator	Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following: - Severe maternal morbidity diagnoses (see list below) - Severe maternal morbidity procedures (see list below) - Discharge disposition of expired Severe Maternal Morbidity Diagnoses: - Cardiac Acute heart failure Acute myocardial infarction Aortic aneurysm Cardiac arrest/ventricular fibrillation Heart failure/arrest during procedure or surgery - Hemorrhage Disseminated intravascular coagulation Shock - Renal Acute renal failure - Respiratory Adult respiratory distress syndrome Pulmonary edema - Sepsis - Other OB Air and thrombotic embolism Amniotic fluid embolism Eclampsia Severe anesthesia complications - Other Medical Puerperal cerebrovascular disorder Sickle cell disease with crisis Severe Maternal Morbidity Procedures: - Blood transfusion - Conversion of cardiac rhythm - Hysterectomy - Temporary tracheostomy - Ventilation
Numerator Exclusions	Not applicable
Denominator Exceptions	None
Measure Steward	The Joint Commission
Measure Scoring	Proportion measure
Measure Type	Outcome measure
Improvement Notation	Improvement noted as a decrease in the rate.
Guidance	In the case of multiple births, map the first delivery date/time (Baby A) as the delivery date/time for the encounter. This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence: 1. The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.* 2. The EGA is obtained from a discrete field in the electronic health record. This option is only used when the calculated EGA is not available. Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery. *ACOG ReVITALize Guidelines for Calculating Gestational Age: Gestational Age = (280-(EDD minus Reference Date))/7 --Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology) --Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery. Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks. 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 QDM page for more information on the QDM.
MIPS Quality ID
Meaningful Measure	Safety
Next Version	No Version Available
Previous Version	No Version Available

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Measure Information	2023 Reporting Period
Title	Severe Obstetric Complications
CMS eCQM ID	CMS1028v1
Short Name	PC-07
NQF Number	Not Applicable
Description	Patients with severe obstetric complications which occur during the inpatient delivery hospitalization.
Initial Population	Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period
Denominator	Inpatient hospitalizations for patients delivering stillborn or live birth with >= 20 weeks, 0 days gestation completed
Denominator Exclusions	Inpatient hospitalizations for patients with confirmed diagnosis of COVID with COVID-related respiratory condition or patients with confirmed diagnosis of COVID with COVID-related respiratory procedure
Numerator	Inpatient hospitalizations for patients with severe obstetric complications (not present on admission that occur during the current delivery encounter) including the following: - Severe maternal morbidity diagnoses (see list below) - Severe maternal morbidity procedures (see list below) - Discharge disposition of expired Severe Maternal Morbidity Diagnoses: - Cardiac Acute heart failure Acute myocardial infarction Aortic aneurysm Cardiac arrest/ventricular fibrillation Heart failure/arrest during procedure or surgery - Hemorrhage Disseminated intravascular coagulation Shock - Renal Acute renal failure - Respiratory Adult respiratory distress syndrome Pulmonary edema - Sepsis - Other OB Air and thrombotic embolism Amniotic fluid embolism Eclampsia Severe anesthesia complications - Other Medical Puerperal cerebrovascular disorder Sickle cell disease with crisis Severe Maternal Morbidity Procedures: - Blood transfusion - Conversion of cardiac rhythm - Hysterectomy - Temporary tracheostomy - Ventilation
Numerator Exclusions	Not applicable
Denominator Exceptions	None
Measure Steward	The Joint Commission
Measure Scoring	Proportion measure
Measure Type	Outcome measure
Improvement Notation	Improvement noted as a decrease in the rate.
Guidance	In the case of multiple births, map the first delivery date/time (Baby A) as the delivery date/time for the encounter. This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence: 1. The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.* 2. The EGA is obtained from a discrete field in the electronic health record. This option is only used when the calculated EGA is not available. Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery. *ACOG ReVITALize Guidelines for Calculating Gestational Age: Gestational Age = (280-(EDD minus Reference Date))/7 --Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology) --Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery. Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks. 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 QDM page for more information on the QDM.
Meaningful Measure	Safety
Next Version	No Version Available
Previous Version	No Version Available

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Value Sets to be used with CMS1028v1