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

Last updated: February 1, 2017

CMS Measure ID: CMS178v6
Version: 6
NQF Number: None
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 principal selected surgeries with hospital stays <= 120 days during the measurement period for patients age 18 and older at the time of hospital admission

Denominator Statement:

All selected surgical patients with a catheter in place postoperatively

Denominator Exclusions:

Patients who had a urinary diversion, or a urethral catheter or were being intermittently catheterized prior to hospital arrival

Patients who expired perioperatively

Patients who expire before the end of (Post-Operative Day 2) POD 2 prior to catheter removal

Patients whose length of stay was less than two days postoperatively

Patients who had physician/APN/PA documentation of a reason for not removing the urinary catheter postoperatively

Patients who had a urological, gynecological or perineal procedure performed during inpatient encounter

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:

In ICU on POD 1 or POD 2 AND receives at least one dose(s) of one or more of the following medications:

  • Diuretic (oral or injectable)
  • IV Positive Inotropic and Vasopressor Agents
  • Paralytic Agents (injectable)
Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Patient Safety
Short Name: SCIPInf9
Previous Version: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

Perioperative death: The patient expired during the timeframe from surgical incision through discharge from the post anesthesia care/recovery area. For patients discharged from surgery and admitted to locations other than the PACU (eg, ICU): The perioperative period would end a maximum of six hours after anesthesia ends.

Postoperatively includes the recovery period, which is defined as 'within 6 hours after the end of anesthesia' for the selected surgeries.

Devices applied such as suprapubic catheters, illeal-conduit urostomy bag, urostomy bag, or ileostomy sets and bags indicate Urinary Diversions.

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

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • ICU admission or transfer <= 2 days starts after start and medications (diuretics, paralytics and inotropic and vasopressor agents) moved from exclusions to denominator exceptions.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Rearranged denominator exclusion list to better align with logic and removed statement related to not having a catheter as those patients would not have been included in denominator.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Replaced the term suprapubic to urethral catheter to align with logic. Suprapubic catheters are captured through urinary diversions.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Updated Endorsed by to 'None.'.

    Section: Endorsed By

    Source: Measure Lead

  • Moved definitions and explanations from denominator and denominator exclusion statements to Guidance to reduce duplication; added definition of perioperative and postoperative periods, and perioperative death to Guidance section; provided explanation of what is indicative of a urinary diversion.

    Section: Guidance

    Source: Measure Lead

  • Revised IP to include principal and to read more clearly.

    Section: Initial Population

    Source: Measure Lead

  • Updated NQF Number to 'Not Applicable.'.

    Section: NQF Number

    Source: Measure Lead

Logic

  • Removed Occurrence A from: Occurrence A ('Encounter, Performed: Emergency Department Visit' <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient because another piece of the Union captures the occurrence.

    Section: Denominator

    Source: Measure Lead

  • Replaced Intervention and Procedure performed with Device, applied for urinary catheters and urinary diversions.

    Section: Denominator

    Source: Measure Lead

  • Revised AND NOT logic by adding (removal datetime) during Occurrence A of $EncounterInpatient to constrain timing.

    Section: Denominator

    Source: Measure Lead

  • Revised the AND NOT logic in the denominator by replacing the Procedure, Performed to Device, Applied to allow the logic to refer to the same catheter throughout and by removing <= 6 hours and adding a removal datetime to enforce timing constraint.

    Section: Denominator

    Source: JIRA (CQM-1735)

  • Logic for ICU admission or transfer <= 2 days starts after start and medications (diuretics, paralytics and inotropic and vasopressor agents) moved to denominator exceptions. Added 'overlaps' operator to timing constraint for better accuracy.

    Section: Denominator Exceptions

    Source: None

  • Replaced Intervention and Procedure performed with Device, applied for urinary catheters and urinary diversions.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Replaced Intervention and Procedure performed with Device, applied for urinary catheters and urinary diversions.

    Introduced variable $UrinaryDiversionCatheterization = Union of: 'Device, Applied: Urinary Diversion'; 'Device, Applied: Urethral Catheter'; and 'Device, Applied: Intermittent Catheterization' to allow re-use of logical expressions and reduce redundancy/complexity.

    Section: Denominator Exclusions

    Source: JIRA (CQM-1677)

  • Revised patient expired logic to account for the patient expiring during the perioperative period to meet measure intent.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Replaced Intervention and Procedure performed with Device, applied for urinary catheters and urinary diversions.

    Section: Numerator

    Source: Measure Lead

  • Value set Devices indicating intermittent catheterization (2.16.840.1.113762.1.4.1111.135): Added Devices indicating intermittent catheterization.

    Section: QDM Data Elements

    Source: None

  • Value set Devices indicating urethral catheter (2.16.840.1.113762.1.4.1111.136): Added Devices indicating urethral catheter.

    Section: QDM Data Elements

    Source: None

  • Value set Devices indicating urinary diversion (2.16.840.1.113762.1.4.1111.133): Added Devices indicating urinary diversion.

    Section: QDM Data Elements

    Source: None

  • Value set Intermittent Catheterization (2.16.840.1.113883.3.666.5.825): Removed Intermittent Catheterization.

    Section: QDM Data Elements

    Source: None

  • Value set SCIP urinary diversion procedures (2.16.840.1.113883.3.666.5.2313): Removed SCIP urinary diversion procedures.

    Section: QDM Data Elements

    Source: None

  • Value set Suprapubic catheter (2.16.840.1.113883.3.666.5.827): Removed Suprapubic catheter.

    Section: QDM Data Elements

    Source: None

  • Value set Urethral catheter placement (2.16.840.1.113762.1.4.1045.74): Removed Urethral catheter placement.

    Section: QDM Data Elements

    Source: None

  • Value set Urethral catheter removal (2.16.840.1.113762.1.4.1111.4): Removed Urethral catheter removal.

    Section: QDM Data Elements

    Source: None

  • Introduced $UrinaryDiversion/Catheterization variable to allow re-use of logical expressions and reduce redundancy/complexity.

    Section: QDM variables

    Source: None

  • Value set Devices indicating intermittent catheterization (2.16.840.1.113762.1.4.1111.135): Added Devices indicating intermittent catheterization.

    Section: QDM Variables

    Source: None

  • Value set Devices indicating urethral catheter (2.16.840.1.113762.1.4.1111.136): Added Devices indicating urethral catheter.

    Section: QDM Variables

    Source: None

  • Value set Devices indicating urinary diversion (2.16.840.1.113762.1.4.1111.133): Added Devices indicating urinary diversion.

    Section: QDM Variables

    Source: None

Value Set

  • Value set Devices indicating intermittent catheterization (2.16.840.1.113762.1.4.1111.135): Added Devices indicating intermittent catheterization.

    Section: None

    Source: None

  • Value set Devices indicating urethral catheter (2.16.840.1.113762.1.4.1111.136): Added Devices indicating urethral catheter.

    Section: None

    Source: None

  • Value set Devices indicating urinary diversion (2.16.840.1.113762.1.4.1111.133): Added Devices indicating urinary diversion.

    Section: None

    Source: None

  • Value set Diuretics (2.16.840.1.113883.3.666.5.829): Added 101 RXNORM codes and deleted 5 RXNORM codes (1233658, 1233851, 282452, 314020, 314029).

    Section: None

    Source: None

  • Value set General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743): Added 3 SNOMEDCT codes (50697003, 74527005, 82776005).

    Section: None

    Source: None

  • Value set IV Positive Inotropic and Vasopressor Agents (2.16.840.1.113883.3.666.5.2128): Added 2 RXNORM codes (1660014, 1666372) and deleted 33 RXNORM codes.

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Paralytic Agents (2.16.840.1.113883.3.666.5.2129): Added 3 RXNORM codes (1594585, 1594589, 1594598) and deleted 6 RXNORM codes (1235036, 204398, 240414, 259033, 315105, 998231).

    Section: None

    Source: None

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