Download OB # Process Measures Numerator Denominator Sample Details 1

OB # Process Measures
1
Elective deliveries before 39 completed wks of
gestation
(% Rate)
Outcome Measures
2
Number of babies ≥37 0/7 weeks
Babies delivered before 39 completed weeks of
gestation to ≤38 6/7 weeks gestation
Number of babies born ≥ 37 0/7
gestation admitted to a higher level of care (e.g. SCN, admitted to a higher level of care (e.g.
weeks to ≤ 38 6/7 weeks
Exclude multiple gestations (singleton pregnancies only)
NICU, transfer) who were electively born
SCN, NICU, transfer) who were electively
gestation
(% Rate)
born (either by elective labor induction or
elective/repeat cesarean)
Process Measures
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MHA Keystone: OB Data Dictionary (20150115)
Early Elective Deliveries
Numerator
Denominator
Sample
Number of births ≥ 37 0/7
Number of elective births ≥ 37 0/7 weeks
weeks to ≤ 38 6/7 weeks
to ≤ 38 6/7 weeks gestation (per the Joint
gestation (per the Joint
Exclude multiple gestations (singleton pregnancies only)
Commission PC-01 criteria & sampling
Commission PC-01 criteria &
guidelines)
sampling guidelines)
Numerator
Denominator
Numerator
Denominator
Post Partum Hemorrhage
Sample
Details
Use Joint Commission PC-01 Criteria & Sampling Guidelines
Details
Numerator includes only non-medically indicated deliveries - these are not elective.
Details
Audit 20 randomly selected charts per month (10 vaginal,
10 cesarean if possible); all charts if less than or equal to
20 per month
Risk assessment for obstetric hemorrhage
documented upon admission
(% Rate)
Number of audited charts with risk
assessments completed and documented Total number of charts audited
upon admission
Women receiving active management of third stage
of labor
(% Rate)
Number of audited charts with
documentation that all women giving
birth vaginally received active
management of third stage labor
Total number of charts audited
Debrief sessions
(% Rate)
Number of debrief forms completed
Number of hemorrhages each
month that required
CMQCC PPH protocol is found in Appendix B of MHA PPH
interventions, treatments,
overview document. Follow same criteria as outcome
procedures outlined in Stage 2 measures for birth > 20 0/7 weeks gestation.
or 3 of the CMQCC PPH Protocol
Outcome Measures
Numerator
Denominator
Blood products transfused during birth admission to
women who gave birth > 20 0/7 weeks gestation
(will be normalized per 1,000 women)
Number of units of any blood product*
(RBCs, FFP, Plt packs, Cryo) transfused
Number of women giving birth
during the birth admission (women giving (>20 0/7 weeks gestation)
birth >20 0/7 weeks gestation)
Women (who gave birth > 20 0/7 weeks gestation)
who were transfused with ≥4 units of any blood
product during the birth
(will be normalized per 1,000 women)
Number of women (who gave birth > 20
0/7 weeks gestation) who were transfused Number of women giving birth
with ≥4 units** any blood product*
(>20 0/7 weeks gestation)
during the birth admission
Risk assessments may be performed by qualified physician or nurse team members
If patient opts out of intervention, disregard and select a
new chart for audit or exclude if less than 20 charts
available
Audit 20 randomly selected charts per month (20 vaginal);
all charts if less than or equal to 20 per month
If patient opts out of intervention, disregard and select a
new chart for audit or exclude if less than 20 charts
available
Sample
Active management of third stage of labor for all vaginal births includes routine
administration of IM or IV infusion (not IV push) of oxytocin with shoulder delivery or
placental delivery
ICD-9 Codes related to Denominator include:
666.00 Third stage labor postpartum hemorrhage unspecified as to episode of care
666.02 Third stage labor postpartum hemorrhage with delivery
666.04 Third stage labor postpartum hemorrhage
666.10 Other immediate postpartum hemorrhage unspecified as to episode of care
666.12 Other immediate postpartum hemorrhage with delivery
666.14 Other immediate postpartum hemorrhage
Details
ICD-9 codes related to Numerator include:
99.04 Transfusion of packed cells
99.05 Transfusion of platelets
99.06 Transfusion of coagulation factors (transfusion of antihemophilic factor) (this is
how cryo is coded)
99.07 Transfusion of other serum (plasma)
ICD-9 Codes related to Numerator include:
Only include women who have delivered, either vaginal or
99.04 Transfusion of packed cells
cesarean, that received transfusion as a result of the
99.05 Transfusion of platelets
delivery. All other instances would be exclusions
99.06 Transfusion of coagulation factors (transfusion of antihemophilic factor) (this is
(transfusions for co-morbidities, other disease processes,
how cryo is coded)
or trauma)
99.07 Transfusion of other serum (plasma)
Only include women who have delivered, either vaginal or
cesarean, that received transfusion as a result of the
delivery. All other instances would be exclusions
(transfusions for co-morbidities, other disease processes,
or trauma)
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9
Process Measures
All pregnant women who present for inpatient care
(does not require official admission) will have a blood
pressure evaluation within 15 minutes of
presentation
(% Rate)
Pregnant women with a blood pressure of equal to or
greater than 160 systolic and/or 110 diastolic on
presentation for inpatient care (does not require
official admission) will be treated with
antihypertensive medications within 1 hour of
presentation
(% Rate)
Preeclampsia
Sample
20 randomly selected cases of pregnant women who
Number of charts in which patients have a
present for inpatient care; likely OB triage unit patients,
blood pressure evaluation within 15
Total number of charts audited however if perinatal service does not have an OB triage
minutes of presentation
unit, then women who present for care directly to the
labor and birth unit
Numerator
Denominator
Number of patients in sample population
with confirmed elevated blood pressure
(initial and 15 minute recheck greater
than 160 systolic and/or 110 diastolic)
that were treated with an
antihypertensive medication (IV Labetalol,
IV Hydralazine, or PO Nifedipine if there is
no IV access) within 1 hour of
presentation
Number of patients with
confirmed elevated blood
pressure (initial and 15 minute
recheck greater than 160
systolic and/or 110 diastolic)
within sample population
Women who meet criteria for preeclampsia with
severe features receive intravenous magnesium
10
sulfate within 1 hour of diagnosis
(% Rate)
Number of patients in sample population
Number of patients diagnosed
that received IV magnesium sulfate within
with preeclampsia with severe
1 hour of diagnosis of preeclampsia with
features
severe features
Women diagnosed with preeclampsia with severe
features and/or eclampsia receive adequate
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discharge instructions
(% Rate)
Number of patients with
Number of patients in sample population
diagnosed with preeclampsia
that received discharge instructions per
with severe features and/or
CMQCC [2014] recommendations
eclampsia
Women diagnosed with preeclampsia with severe
features and/or eclampsia instructed to attend early
follow-up appointments post discharge per the
following recommendations:
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Number of patients in sample population
Number of patients with the
instructed to attend a follow-up
following ICD-9 codes: 642.5,
The follow-up appointment should occur within 3-7 appointment per recommendations in
642.6, 642.7
days if BP medication was used during labor, birth or Structure Measure
postpartum and within 7-14 days if the diagnosis of
preeclampsia was made but no medication was used.
(% Rate)
Details
Examine patients with the following ICD-9 codes and all
subsets: 642.5, 642.6, 642.7
If blood pressure is elevated equal to or greater than 160 systolic and/or 110 diastolic,
Please note: The given ICD-9 codes were chosen to narrow recheck in 15 minutes. If still elevated, proceed with treatment.
the focus of the projet and target the patient population
that most closely matches the ACOG criteria
Examine patients with the following ICD-9 codes and all
subsets: 642.5, 642.6
Criteria for preeclampsia with severe features found in Appendix C of MHA Preeclampsia
overview document
Please note: The given ICD-9 codes were chosen to narrow
Note: For the purposes of data collection, it is acceptable to measure time of magnesium
the focus of the projet and target the patient population
sulfate order to time of magnesium sulfate administration to patient.
that most closely matches the ACOG criteria
Examine patients with the following ICD-9 codes and all
subsets: 642.5, 642.6
Criteria for preeclampsia with severe features found in Appendix C of MHA Preeclampsia
overview document
Please note: The given ICD-9 codes were chosen to narrow
CMQCC Sample Written Discharge Instructions are found in Appendix D of MHA
the focus of the projet and target the patient population
Preeclampsia overview document
that most closely matches the ACOG criteria
Examine patients with the following ICD-9 codes and all
subsets: 642.5, 642.6, 642.7
CMQCC guidelines and care algorithms found in Appendices B and E of MHA
Preeclampsia overview document
ACOG 2013 recommendations on hypertension found in Appendix C of MHA
Please note: The given ICD-9 codes were chosen to narrow Preeclampsia overview document
the focus of the projet and target the patient population
that most closely matches the ACOG criteria
ACOG 2013 recommendations regarding hypertension (full text) linked in Reference
Documents section as well as in MHA Community library entry
All data submitted monthly
Reference Documents
Joint Commission PC-01 criteria
Joint Commission PC-01 Sampling Guidelines
Overviews, Documents, and Toolkits on the MHA Community
ACOG 2013 Hypertension in Pregnancy
*The numerators identify all blood products rather than just RBCs. This is the definition used by the Joint Commission and supported by an ACOG/CDC/SMFM consensus committee.
**The definition of an obstetric sentinel event including transfusion of ≥4 units of blood products is currently in consideration by The Joint Commission.