Hospital Harm - Postoperative Respiratory Failure

Measure Information	2026 Reporting Period
Title	Hospital Harm - Postoperative Respiratory Failure
CMS eCQM ID	CMS1218v1
Short Name	HH-RF
CBE ID*	4130e
Measure Steward	Centers for Medicare & Medicaid Services (CMS)
Description	This measure assesses the number of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF)
Measure Scoring	Proportion measure
Measure Type	Outcome
Stratification	None
Risk Adjustment	Variables are collected for the development of baseline risk adjustment model Report the first resulted vital sign values during the encounter in the Unified Code for Units of Measure (UCUM) units specified: - Body temperature: Cel, [degF] - Heart rate: {Beats}/min - Respiratory rate:... {Breaths}/min - Systolic blood pressure: mm[Hg] Report the first resulted laboratory test values during the encounter in UCUM units specified: - Albumin: g/dL, umol/L - Aspartate aminotransferase (AST/SGOT): U/L, IU/L - Bicarbonate: mmol/L - Bilirubin: mg/dL, umol/L - Blood urea nitrogen (BUN): mg/dL, umol/L - Carbon dioxide (partial pressure): mm[Hg] - Creatinine: mg/dL, umol/L - Hematocrit: % - Hemoglobin: g/dL, mmol/L - Leukocyte count: {cells}/uL, 103/uL, 109/L, /mm3 - Oxygen (partial pressure): mm[Hg] - pH of arterial blood: [pH] - Platelet count: 103/uL, 109/L, /mm3 - Sodium: meq/L, mmol/L - White blood cell count: {cells}/uL, 103/uL, 109/L, /mm3 Additional variables used for risk adjustment: - American Society of Anesthesiologists (ASA) physical status class assessment that starts during the encounter - First Body mass index (BMI), reported using UCUM unit: kg/m2 - Encounter diagnoses with their present on admission (POA) indicators - Most recent smoking status - Principal surgical procedures that start during the encounter Please see the Hospital Harm - Postoperative Respiratory Failure Risk Adjustment Methodology Report on the eCQM-specific page on the eCQI Resource Center website: https://ecqi.healthit.gov/ Show more > Variables are collected for the development of baseline risk adjustment model Report the first resulted vital sign values during the encounter in the Unified Code for Units of Measure (UCUM) units specified: - Body temperature: Cel, [degF] - Heart rate: {Beats}/min - Respiratory rate: {Breaths}/min - Systolic blood pressure: mm[Hg] Report the first resulted laboratory test values during the encounter in UCUM units specified: - Albumin: g/dL, umol/L - Aspartate aminotransferase (AST/SGOT): U/L, IU/L - Bicarbonate: mmol/L - Bilirubin: mg/dL, umol/L - Blood urea nitrogen (BUN): mg/dL, umol/L - Carbon dioxide (partial pressure): mm[Hg] - Creatinine: mg/dL, umol/L - Hematocrit: % - Hemoglobin: g/dL, mmol/L - Leukocyte count: {cells}/uL, 103/uL, 109/L, /mm3 - Oxygen (partial pressure): mm[Hg] - pH of arterial blood: [pH] - Platelet count: 103/uL, 109/L, /mm3 - Sodium: meq/L, mmol/L - White blood cell count: {cells}/uL, 103/uL, 109/L, /mm3 Additional variables used for risk adjustment: - American Society of Anesthesiologists (ASA) physical status class assessment that starts during the encounter - First Body mass index (BMI), reported using UCUM unit: kg/m2 - Encounter diagnoses with their present on admission (POA) indicators - Most recent smoking status - Principal surgical procedures that start during the encounter Please see the Hospital Harm - Postoperative Respiratory Failure Risk Adjustment Methodology Report on the eCQM-specific page on the eCQI Resource Center website: https://ecqi.healthit.gov/ Show less
Rationale	Postoperative respiratory failure (PRF), defined as unplanned endotracheal reintubation, prolonged inability to wean from mechanical ventilation, or inadequate oxygenation and/or ventilation, is the most common serious postoperative pulmonary complication, with an incidence of up to 7.5%... (the incidence of any postoperative pulmonary complication ranges from 10-40%) (Arozullah et al., 2000; Canet et al., 2015; Gupta et al., 2011; Kor et al., 2014). This measure addresses the prevalence of PRF and the variance between hospitals in the incidence of PRF. PRF is a serious complication that can increase the risk of morbidity and mortality, with in-hospital mortality resulting from PRF estimated at 25% to 40% (Arozullah et al., 2000; Canet & Gallart, 2014). Surgical procedures complicated by PRF have 3.74 times higher adjusted odds of death than those not complicated by respiratory failure, 1.47 times higher odds of 90-day readmission, and 1.86 times higher odds of an outpatient visit with one of 44 postoperative conditions (e.g., bacterial infection, fluid and electrolyte disorder, abdominal hernia) within 90 days of hospital discharge (Miller et al., 2001; Romano et al, 2009). PRF is additionally associated with prolonged mechanical ventilation and the need for rehabilitation or skilled nursing facility placement upon discharge (Thompson & Lisco, 2018). The incidence of PRF varies by hospital, with higher reported rates of PRF in nonteaching hospitals than teaching hospitals (Rahman et al., 2013). Additionally, one study found that the odds of developing PRF increased by 6% for each level increase in hospital size from small to large (Rahman et al., 2013). This suggests that there remains room for improvement in hospitals reporting higher rates of PRF. The most widely used current measures of PRF are based on either claims data (CMS Patient Safety Indicator (PSI) 11) or proprietary registry data (National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons). The proposed eCQM is closely modeled after the NSQIP measure of PRF, which has been widely adopted across American hospitals, and is intended to complement and eventually supplant CMS PSI 11. Show more > Postoperative respiratory failure (PRF), defined as unplanned endotracheal reintubation, prolonged inability to wean from mechanical ventilation, or inadequate oxygenation and/or ventilation, is the most common serious postoperative pulmonary complication, with an incidence of up to 7.5% (the incidence of any postoperative pulmonary complication ranges from 10-40%) (Arozullah et al., 2000; Canet et al., 2015; Gupta et al., 2011; Kor et al., 2014). This measure addresses the prevalence of PRF and the variance between hospitals in the incidence of PRF. PRF is a serious complication that can increase the risk of morbidity and mortality, with in-hospital mortality resulting from PRF estimated at 25% to 40% (Arozullah et al., 2000; Canet & Gallart, 2014). Surgical procedures complicated by PRF have 3.74 times higher adjusted odds of death than those not complicated by respiratory failure, 1.47 times higher odds of 90-day readmission, and 1.86 times higher odds of an outpatient visit with one of 44 postoperative conditions (e.g., bacterial infection, fluid and electrolyte disorder, abdominal hernia) within 90 days of hospital discharge (Miller et al., 2001; Romano et al, 2009). PRF is additionally associated with prolonged mechanical ventilation and the need for rehabilitation or skilled nursing facility placement upon discharge (Thompson & Lisco, 2018). The incidence of PRF varies by hospital, with higher reported rates of PRF in nonteaching hospitals than teaching hospitals (Rahman et al., 2013). Additionally, one study found that the odds of developing PRF increased by 6% for each level increase in hospital size from small to large (Rahman et al., 2013). This suggests that there remains room for improvement in hospitals reporting higher rates of PRF. The most widely used current measures of PRF are based on either claims data (CMS Patient Safety Indicator (PSI) 11) or proprietary registry data (National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons). The proposed eCQM is closely modeled after the NSQIP measure of PRF, which has been widely adopted across American hospitals, and is intended to complement and eventually supplant CMS PSI 11. Show less
Clinical Recommendation Statement	Recent studies and current clinical practice guidelines for PRF have identified enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, lung protective intraoperative ventilation, prophylactic respiratory physiotherapy, epidural... analgesia, and goal directed hemodynamic therapy as evidence-based interventions to reduce the incidence of PRF. Yet, progress in reducing the incidence of PRF has been stymied by lack of consensus regarding the definition of PRF, which patients are most at-risk, which risk factors are potentially modifiable, and which patients are more likely to benefit from targeted interventions of a health care system’s limited resources. This measure would address this gap in data. Show more > Recent studies and current clinical practice guidelines for PRF have identified enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, lung protective intraoperative ventilation, prophylactic respiratory physiotherapy, epidural analgesia, and goal directed hemodynamic therapy as evidence-based interventions to reduce the incidence of PRF. Yet, progress in reducing the incidence of PRF has been stymied by lack of consensus regarding the definition of PRF, which patients are most at-risk, which risk factors are potentially modifiable, and which patients are more likely to benefit from targeted interventions of a health care system’s limited resources. This measure would address this gap in data. Show less
Improvement Notation	A lower measure score indicates higher quality
Definition	Inpatient hospitalizations: Includes time in outpatient surgery service or observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. "Elective Inpatient Encounter" value set intends to capture all... scheduled hospitalizations and excludes emergency, urgent, and unplanned admissions. Elective surgical procedures: Elective is modeled by specifying an elective inpatient admission encounter type with an encounter class of ‘elective’. Surgical procedure is referred to as an "Operating Room (OR) procedure" or "procedure" and is modeled by the use of anesthesia during the encounter. These combined concepts determine a qualifying elective surgical procedure occurred. The ‘First’ OR procedure of the encounter is captured by an administration of general or neuraxial anesthesia, typically only given and monitored within an operating room environment. These anesthesia concepts are included in the ‘General or Neuraxial Anesthesia’ value set. All other subsequent procedures are captured by an administration of general, neuraxial, regional anesthesia and conscious sedation that requires monitored anesthesia care (MAC) regardless of procedural area location. These anesthesia concepts are included in the "Anesthesia Requiring Monitored Care" value set. Procedural area locations include operating rooms, endoscopy, cardiac catheterization and interventional radiology suites. Procedural area locations are also defined by areas where there is an administration of general, neuraxial, regional anesthesia or conscious sedation that requires MAC. Non-invasive oxygen therapy refers to patients on room air, nasal cannula, face masks, or continuous or intermittent positive airway pressure devices. Show more > Inpatient hospitalizations: Includes time in outpatient surgery service or observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. "Elective Inpatient Encounter" value set intends to capture all scheduled hospitalizations and excludes emergency, urgent, and unplanned admissions. Elective surgical procedures: Elective is modeled by specifying an elective inpatient admission encounter type with an encounter class of ‘elective’. Surgical procedure is referred to as an "Operating Room (OR) procedure" or "procedure" and is modeled by the use of anesthesia during the encounter. These combined concepts determine a qualifying elective surgical procedure occurred. The ‘First’ OR procedure of the encounter is captured by an administration of general or neuraxial anesthesia, typically only given and monitored within an operating room environment. These anesthesia concepts are included in the ‘General or Neuraxial Anesthesia’ value set. All other subsequent procedures are captured by an administration of general, neuraxial, regional anesthesia and conscious sedation that requires monitored anesthesia care (MAC) regardless of procedural area location. These anesthesia concepts are included in the "Anesthesia Requiring Monitored Care" value set. Procedural area locations include operating rooms, endoscopy, cardiac catheterization and interventional radiology suites. Procedural area locations are also defined by areas where there is an administration of general, neuraxial, regional anesthesia or conscious sedation that requires MAC. Non-invasive oxygen therapy refers to patients on room air, nasal cannula, face masks, or continuous or intermittent positive airway pressure devices. Show less
Guidance	PRF is evaluated using mechanical ventilation (MV) documentation or intubation and extubation documentation to allow for hospital documentation variances. Therefore, if MV documentation is not available, intubation and extubation can serve as a proxy for determining if MV occurred and... its duration. To determine that an unplanned initiation of MV occurred, the logic looks for evidence of a non-invasive oxygen therapy assessment such as oxygen via 'nasal canula' or 'breathing room air' prior to the MV occurrence to verify that MV was newly initiated. Additionally, facility location codes are used to determine if MV was initiated outside of a procedural area (e.g., medical floor). Conversely, to determine MV duration, the logic looks for evidence that a non-invasive oxygen therapy assessment or another operating room procedure does not exist prior to the MV occurrence to verify that MV was continued without interruption from a procedural area. 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. Show more > PRF is evaluated using mechanical ventilation (MV) documentation or intubation and extubation documentation to allow for hospital documentation variances. Therefore, if MV documentation is not available, intubation and extubation can serve as a proxy for determining if MV occurred and its duration. To determine that an unplanned initiation of MV occurred, the logic looks for evidence of a non-invasive oxygen therapy assessment such as oxygen via 'nasal canula' or 'breathing room air' prior to the MV occurrence to verify that MV was newly initiated. Additionally, facility location codes are used to determine if MV was initiated outside of a procedural area (e.g., medical floor). Conversely, to determine MV duration, the logic looks for evidence that a non-invasive oxygen therapy assessment or another operating room procedure does not exist prior to the MV occurrence to verify that MV was continued without interruption from a procedural area. 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. Show less
Initial Population	Elective inpatient hospitalizations with no preceding emergency department visit that end during the measurement period for patients aged 18 and older without an obstetrical condition and at least one surgical procedure was performed within the first 3 days of the encounter ... Show more > Elective inpatient hospitalizations with no preceding emergency department visit that end during the measurement period for patients aged 18 and older without an obstetrical condition and at least one surgical procedure was performed within the first 3 days of the encounter Show less
Denominator	Equals Initial Population
Denominator Exclusions	Inpatient hospitalizations for patients: With a diagnosis for a degenerative neurological disorder With any selected head, neck, and thoracic surgery involving significant risk of airway compromise or requiring airway protection Who have mechanical ventilation that starts more than one hour... prior to the start of the first operating procedure (OR) procedure With a diagnosis for a neuromuscular disorder With arterial partial pressure of carbon dioxide (PaCO2)>50 mmHg combined with an arterial pH<7.30 within 48 hours or less prior to the start of the first OR procedure With arterial partial pressure of oxygen (PaO2)<50 mmHg within 48 hours or less prior to the start of the first OR procedure With a principal diagnosis for acute respiratory failure With a secondary diagnosis for acute respiratory failure present on admission With any diagnosis present on admission for the existence of a tracheostomy Where a tracheostomy is performed before or on the same day as the first OR procedure Show more > Inpatient hospitalizations for patients: With a diagnosis for a degenerative neurological disorder With any selected head, neck, and thoracic surgery involving significant risk of airway compromise or requiring airway protection Who have mechanical ventilation that starts more than one hour prior to the start of the first operating procedure (OR) procedure With a diagnosis for a neuromuscular disorder With arterial partial pressure of carbon dioxide (PaCO2)>50 mmHg combined with an arterial pH<7.30 within 48 hours or less prior to the start of the first OR procedure With arterial partial pressure of oxygen (PaO2)<50 mmHg within 48 hours or less prior to the start of the first OR procedure With a principal diagnosis for acute respiratory failure With a secondary diagnosis for acute respiratory failure present on admission With any diagnosis present on admission for the existence of a tracheostomy Where a tracheostomy is performed before or on the same day as the first OR procedure Show less
Numerator	Elective inpatient hospitalizations for patients with postoperative respiratory failure as evidenced by any of the following: Criterion A: Mechanical ventilation (MV) initiated within 30 days after first OR procedure, as evidenced by: A.1. Intubation that occurs outside of a procedural... area and within 30 days after the end of the first OR procedure of the encounter. or A.2. MV that occurs outside of a procedural area within 30 days after the end of the first OR procedure of the encounter and is preceded by a period of non-invasive oxygen therapy between the end of the OR procedure and the MV occurrence, and without a subsequent OR procedure between the non-invasive oxygen therapy and the MV occurrence. or Criterion B: MV with a duration of more than 48 hours after the first OR procedure, as evidenced by: B.1. Extubation that occurs outside of a procedural area more than 48 hours after the end of an OR procedure and within 30 days after the end of the first OR procedure, and is not preceded by a period of non-invasive oxygen therapy or a subsequent OR procedure between the end of the OR procedure and the extubation occurrence. or B.2 Mechanical ventilation that occurs between 48 and 72 hours after the end of an OR procedure and within 30 days after the end of the first OR procedure, and is not preceded by a non-invasive oxygen therapy or a subsequent OR procedure between the end of the OR procedure and the MV occurrence.  Show more > Elective inpatient hospitalizations for patients with postoperative respiratory failure as evidenced by any of the following: Criterion A: Mechanical ventilation (MV) initiated within 30 days after first OR procedure, as evidenced by: A.1. Intubation that occurs outside of a procedural area and within 30 days after the end of the first OR procedure of the encounter. or A.2. MV that occurs outside of a procedural area within 30 days after the end of the first OR procedure of the encounter and is preceded by a period of non-invasive oxygen therapy between the end of the OR procedure and the MV occurrence, and without a subsequent OR procedure between the non-invasive oxygen therapy and the MV occurrence. or Criterion B: MV with a duration of more than 48 hours after the first OR procedure, as evidenced by: B.1. Extubation that occurs outside of a procedural area more than 48 hours after the end of an OR procedure and within 30 days after the end of the first OR procedure, and is not preceded by a period of non-invasive oxygen therapy or a subsequent OR procedure between the end of the OR procedure and the extubation occurrence. or B.2 Mechanical ventilation that occurs between 48 and 72 hours after the end of an OR procedure and within 30 days after the end of the first OR procedure, and is not preceded by a non-invasive oxygen therapy or a subsequent OR procedure between the end of the OR procedure and the MV occurrence.  Show less
Numerator Exclusions	Not Applicable
Denominator Exceptions	None
Next Version	No Version Available
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This is a risk adjusted measure. Risk Adjustment Summary Report: Hospital Harm – Postoperative Respiratory Failure
There is a known issue on CMS1218v1. See issue EKI-29 on the ONC eCQM Known Issues Dashboard for details.

Hospital Harm - Postoperative Respiratory Failure

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