ORYX PLUS Measures

PERIOPERATIVE MEASURES

u OP1 Numerator: Patients developing a central nervous system, peripheral neurological deficit, acute myocardial infarction complication or having a cardiac arrest within two post-procedure days of procedures involving anesthesia administration.

Denominator: All patients undergoing specified procedures involving anesthesia.

u OP2 Numerator: Intrahospital mortality of patients within two post-procedure days of procedures involving anesthesia administration.

Denominator: All patients undergoing specified procedures involving anesthesia.

OBSTETRIC MEASURES

u OP3 Numerator: Patients delivered by cesarean.

Denominator: All deliveries.

u OP4 Numerator: Patients with vaginal birth after cesarean.

Denominator: Patients delivered with a history of previous cesarean.

u OP5 Numerator: Live-born infants with a birth weight of less than 2,500 grams.

Denominator: All live births.

u OP6 Numerator: Live-born infants with a birth weight greater than or equal to 2,500 grams, who have at least one of the following: an Apgar score of less than 4 at five minutes, a requirement for admission to the neonatal intensive care unit within one day of delivery for greater than one day, a clinically apparent seizure, or significant birth trauma.

Denominator: All live-born infants with a birth weight greater than or equal to 2,500 grams.

CARDIOVASCULAR MEASURES

u OP7 Indicator Statement: Patients undergoing isolated coronary artery bypass graft (CABG) procedures: number of days from initial surgery to discharge.

u OP8 Indicator Statement: Patients undergoing a percutaneous transluminal coronary angioplasty (PTCA): number of days from procedure to discharge.

u OP9 Numerator: Intrahospital mortality of patients undergoing an isolated CABG.

Denominator: Patients undergoing an isolated CABG.

u OP10 Numerator: Intrahospital mortality of patients undergoing a PTCA.

Denominator: Patients undergoing a PTCA.

u OP11 Numerator: Intrahospital mortality of patients with a principal discharge diagnosis of acute myocardial infarction.

Denominator: Patients with a principal discharge diagnosis of acute myocardial infarction.

u OP12 Indicator Statement: Patients admitted through the emergency department (ED) receiving thrombolytic therapy who have a principal discharge diagnosis of acute myocardial infarction and ST segment elevation on their initial electrocardiograms: time from ED arrival to administration of thrombolytic therapy. (Indicator statement as contrasted with a numerator is used when the measure is a continuous variable.)

TRAUMA MEASURES

u OP13 Numerator: Trauma patients with systolic blood pressure, pulse rate, and respiratory rate documented on arrival to the ED or Trauma Unit (TU), and at least hourly for three hours [or until ED patient is released or the TU patient is discharged].

Denominator: All trauma patients.

u OP14 Numerator: Trauma patients with specified intracranial injuries with Glasgow coma scale (GCS) score documented on arrival to ED or TU, and at least hourly for three hours [or until ED patient is released or the TU patient is discharged].

Denominator: Trauma patients with specified intracranial injuries.

u OP15 Indicator Statement: Trauma patients with head computerized tomography (CT) scan performed: time from ED arrival to initial CT scan.

u OP16 Indicator Statement: Trauma patients undergoing specified neurosurgical procedures: time from ED arrival to procedure.

u OP17 Indicator Statement: Trauma patients undergoing specified orthopedic procedures: time from ED arrival to procedure.

u OP18 Indicator Statement: Trauma patients undergoing specified abdominal surgical procedures: time from ED arrival to procedure.

Trauma patients: Patients undergoing emergency hospital care for at least one of the diagnoses listed on ICD-9-CM Code Table 6, General Trauma Population Codes AND who were admitted, transferred, or expired.

ONCOLOGY MEASURES

u OP19 Numerator: Patients undergoing resection for primary cancer of the lung, colon/rectum, or female breast with stage of tumor designated by a managing physician.

Denominator: Patients undergoing resection for primary cancer of the lung, colon/rectum, or female breast.

u OP20 Numerator: Female patients with Stage I or greater primary breast cancer who, after initial biopsy or resection, have estrogen receptor analysis results in the medical record.

Denominator: Female patients with Stage I or greater primary breast cancer undergoing initial biopsy or resection.

u OP21 Numerator: Patients with non-small cell primary lung cancer undergoing thoracotomy with complete surgical resection of tumor.

Denominator: Patients with non-small cell primary lung cancer undergoing thoracotomy.

u OP22 Numerator: Patients undergoing resection for primary cancer of the colon/rectum whose preoperative evaluation, by a managing physician, included examination of the entire colon.

Denominator: Patients undergoing resection for primary cancer of the colon/rectum.

MEDICATION USE MEASURES

u OP23 Numerator: Inpatients 65 or older in whom creatinine clearance has been estimated or measured.

Denominator: Inpatients 65 years of age or older.

u OP24 Numerator: Inpatients with a discharge diagnosis of insulin-dependent diabetes mellitus who demonstrate self blood glucose monitoring and self-administration of insulin before discharge, or are referred for post-discharge follow-up for diabetes management.

Denominator: Inpatients with a discharge diagnosis of insulin-dependent diabetes mellitus.

u OP25 Numerator: Inpatients receiving digoxin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit.

Denominator: Inpatients receiving digoxin.

u OP26 Numerator: Inpatients receiving theophylline who have no corresponding measured drug level or whose highest measured level exceeds a specific limit.

Denominator: Inpatients receiving theophylline.

u OP27 Numerator: Inpatients receiving phenytoin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit.

Denominator: Inpatients receiving phenytoin.

u OP28 Numerator: Inpatients receiving lithium who have no corresponding measured drug level or whose highest measured level exceeds a specific limit.

Denominator: Inpatients receiving lithium.

u OP29 Indicator Statement: Selected surgical procedures for which prophylactic intravenous antibiotics were received: timing of prophylactic antibiotic administration.

Six Surgical Procedure Groups to select from: appendectomy; coronary artery bypass graft procedures (chest and leg incision/chest incision only); cholecystectomy; colon surgery; hip prosthesis; mastectomy.

INFECTION CONTROL MEASURES

u OP30 Numerator: Selected inpatient and outpatient surgical procedures complicated by a surgical site infection.

Denominator: All patients undergoing selected inpatient and outpatient surgical procedures.

u OP31 Numerator: Ventilated inpatients who develop pneumonia.

Denominator: Inpatient ventilator days.

Six Intensive Care Units (ICUs) to select from: coronary care ICU; medical ICU; medical-surgical ICU; pediatric ICU; respiratory ICU; surgical ICU.

u OP32 Numerator: Inpatients with a central or umbilical line who develop primary blood stream infection.

Denominator: Inpatient central or umbilical line days.

Six Intensive Care Units (ICUs) to select from: coronary care ICU; medical ICU; medical-surgical ICU; pediatric ICU; respiratory ICU; surgical ICU.