Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero

Last updated: July 12, 2017

CMS Measure ID: CMS178v5
Version: 5
NQF Number: 0453
Measure Description:

Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.

Initial Patient Population:

All hospital discharges for selective surgery with hospital stays <= 120 days during the measurement period for patients age 18 and older at the time of hospital admission and who have a Principal Procedure Code of selected surgeries.

Measure Population:

Not applicable

Measure Observations:

Not applicable

Denominator Statement:

All selected surgical patients 18 years of age and older with a catheter placed between hospital arrival and the end of the recovery period, defined as within 6 hours after the end of anesthesia for a SCIP selected surgery as defined in the Initial Population. The catheter must still be in place after the end of the recovery period.

Denominator Exclusions:
  • Patients who had a urological, gynecological or perineal procedure performed.
  • Patients who expired perioperatively.
  • Patients whose length of stay was less than two days postoperatively.
  • Patients who had a urinary diversion or a suprapubic catheter or were being intermittently catheterized prior to hospital arrival.
  • Patients who did not have a catheter in place postoperatively.
  • Patients who had physician/APN/PA documentation of a reason for not removing the urinary catheter postoperatively.
  • In ICU on POD 1 or POD 2 AND receives at least one or more dose(s) of one or more of the following medications:
    • Diuretic
    • Vasopressor/inotropic
    • Paralytic
Numerator Statement:

Number of surgical patients whose urinary catheter is removed on postoperative day (POD) 1 or postoperative day (POD) 2 with day of surgery being day zero.

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Patient Safety
Short Name: SCIPInf9
Next Version: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero
Previous Version: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in rate.

Guidance:

The measurement period is one calendar year but the reporting period is 3 months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul - Sep, Q4 = Oct - Dec.

Denominator element guidance:

The denominator in this measure specifically excludes surgical procedures that may be associated with post-operative indwelling urinary catheter usage and that occur in close time proximity to the index major surgical procedure.

Specifications

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Updated Guidance.
  • Updated the Denominator Exclusions narrative in the header for the removal of clinical participants and to better align with logic.
  • Updated the Denominator header statement to better align with measure logic.
  • Updated the Initial Population header statement to better align with measure logic.

Logic

  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions and/or 'satisfies Any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced 'satisfies any' function to replace previously used operator and to streamline expression (or Denominator Exclusions in this case) logic.
  • Introduced the new timing operator overlaps to replace two lines of logic (AND/AND NOT) or to enforce when an event or set of events occur to meet the measure intent.
  • Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity .
  • Added logic to the Denominator to ensure patients who present in the ED and have a catheter placed will be counted in the Denominator.
  • Changed logic to represent timing from arrival at either the ED or as an inpatient direct admit through the end of the recovery period, which is less than or equal to 6 hours after the end of the anesthesia. This timing was based on encounter and procedure start and stop times rather than value sets to give more precise meaning for extracting data from an EHR.
  • Patient Characteristic Expired is fixed to SNOMED code 419099009 (Dead) and therefore cannot be further qualified with a value set.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The >=1 minutes starts before the start of the Encounter, Performed: Inpatient Encounter timing was changed to 'overlaps Occurrence A of $EncounterInpatient'.
  • The attribute of 'ordinality: Principal' was removed from 'Procedure, Performed: Hospital Measures-SCIP Urological/Perineal procedures with potential need of indwelling catheters'. This was done because patients who have a principal urological or perineal procedure which is found in the SCIP Major Surgical value set will be in the IP, and thus in the Denominator. If they have a urological/perineal procedure which is not the principal procedure, they will be excluded from the Denominator.
  • Removed logic for Clinical Trial Participant from the Denominator Exclusions.
  • The logic for ICU and PACU locations was changed throughout the measure to use the value set 'ICU Admission or Transfer'. The datatype is Encounter, Performed: ICU Admission or Transfer. This Encounter will have a start datetime and end datetime and the timing operators for the medications given in ICU are based on this datatype.
  • The value set for “Indwelling Urinary Catheter” was replaced with a value set for “Urethral catheter placement” in the Denominator. This new value set only has codes in it for placement of the urinary catheter. All other codes (codes for removal of catheter, for instance) were removed. This value set was then used in the Denominator logic to represent the placement of the catheter during the Encounter. The indwelling catheter present during admission logic in the Denominator Exclusions was removed as it is now accounted for in the Denominator with logic representing catheter has to be placed during the ED encounter or Inpatient Encounter.

Value Sets

  • Additional SNOMED codes which map to ICD9CM codes were added to this value set SCIP Major Surgical Procedure (OID 2.16.840.1.113883.3.666.5.1250).
  • Separate value sets have been created for urethral catheter placement (OID: 2.16.840.1.113762.1.4.1045.74) and urethral catheter removal (OID: 2.16.840.1.113762.1.4.1111.4). These are now used in logic when required to represent either insertion or removal of the urinary catheter.
  • The value set was removed from Patient Characteristic Expired: Expired as it is now fixed to a single SNOMED code: 419099009 (Dead) and cannot further be qualified with a value set.
  • Value set Clinical Trial Participant (OID 2.16.840.1.113883.3.526.2.643): Removed value set from this measure.
  • Value set Diuretics (OID 2.16.840.1.113883.3.666.5.829): Deleted 3 RXNORM code (197393,250376, 250377) and added 3 RXNORM codes (197788, 250376, 250377).
  • Value Set Emergency Department Visit (OID 2.16.840.1.113883.3.117.1.7.1.292): Added value set to this measure.
  • Value set Hospital Measures-PACU (OID 2.16.840.1.113883.3.666.5.248): Removed value set from his measure and replaced with value set ICU Admission or Transfer (OID 2.16.840.1.113883.3.117.1.7.1.305).
  • Value set Indwelling urinary catheter (OID 2.16.840.1.113762.1.4.1045.74): Updated value set name from Indwelling urinary catheter to Urethral catheter placement. Deleted 1 ICD10PCS (0TPDX0Z) code and 4 SNOMED codes (286738000, 429723008, 43748006, 55449009) and added 1 SNOMED code (225088003).
  • Value set Intermittent Catheterization (OID 2.16.840.1.113883.3.666.5.825): Updated value set name from Hospital Measures-Intermittent Catheterization to Intermittent Catheterization.
  • Value Set IV Positive Inotropic and Vasopressor Agents (OID 2.16.840.1.113883.3.666.5.2128): Deleted 1 RXNORM code (310984).
  • Value set Paralytic Agents (OID 2.16.840.1.113883.3.666.5.2129): Deleted 7 RXNORM codes (238176, 238177, 238178, 238179, 260256, 313121, 727652).
  • Value set SCIP Major Surgical Procedure (OID: 2.16.840.1.113883.3.117.1.7.1.2): Deleted 2 ICD9CM and 451 SNOMED codes and added 1 ICD10PCS and 98 SNOMED codes.
  • Value set SCIP urinary diversion (OID 2.16.840.1.113883.3.666.5.822): Removed value set from this measure.
  • Value set SCIP urinary diversion procedures (OID 2.16.840.1.113883.3.666.5.2313): Updated value set name from Hospital Measures-SCIP urinary diversion procedures to SCIP urinary diversion procedures and added 1 SNOMED code (119560006).
  • Value set SCIP Urological/Perineal procedures with potential need of indwelling catheters (OID 2.16.840.1.113883.3.666.5.2310): Updated value set name from Hospital Measures-SCIP Urological/Perineal procedures with potential need of indwelling catheters to SCIP Urological/Perineal procedures with potential need of indwelling catheters. Deleted 319 SNOMED codes and added 283 ICD10PCS and 38 SNOMED codes.
  • Value set Suprapubic catheter (OID 2.16.840.1.113883.3.666.5.827): Updated value set name from Hospital Measures-Suprapubic catheter to Suprapubic catheter.

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