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Risk Adjusted Urinary Tract Infection Outcome Measure After Surgery

CBE ID
0751
1.4 Project
Patient Safety
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Spring 2018
Is Under Review
No
1.3 Measure Description

Risk adjusted, case mix adjusted urinary tract infection outcome measure of adults 18+ years after surgical procedure.

    • 1.14 Numerator

      The outcome of interest is a hospital-specific assessment of risk-adjusted Urinary Tract Infection (UTI: as defined by American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)defined below) within 30 days of any listed (CPT) surgical procedure: the list of eligible CPT codes is attached separately.

    • 1.15 Denominator

      Patients undergoing any of the listed (CPT) surgical procedures- list is attached separately. Specifically excluded are certain CPTs involving the urinary tract (excluded: 50220, 50545, 50400, 50205, 51040, 54640, 53852, 55866, 52450, 52234). See attached submitted list of eligible CPT codes.

    • Exclusions

      Major trauma and transplant surgeries are excluded as are surgeries not on the supplied CPT list as eligible for selection. Patients who are ASA 6 (brain-death organ donor) are not eligible surgical cases.
      A patient who has a second surgical procedure performed within 30 days after an index procedure cannot be accrued into the measure as a new (second) index procedure since the measure is based on 30 day outcomes.

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Patient Safety Spring Cycle 2018
      Initial Endorsement
      Last Updated
      Removal Date
    • Steward
      American College of Surgeons
      Steward Organization Email
      [email protected]
      Steward Organization Copyright

      UPDATED CONDITIONS SECTION:
      Type of measure * Outcome
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      A. The measure steward is a governmental organization or a Measure Steward Agreement is signed.
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      Yes
      Please check if either of the following apply
      Proprietary measure
      Measure Steward Agreement *
      Agreement will be signed and submitted prior to or at the time of measure submission
      B. The measure owner/steward verifies there is an identified responsible entity and process to maintain and update the measure on a schedule that is commensurate with the rate of clinical innovation, but at least every 3 years. *
      Yes, information will be provided in the contact section (in the Additional tab)
      C. The intended use of the measure includes both public reporting and quality improvement.
      Purpose *
      Public reporting
      Internal quality improvement
      Additional purposes
      None
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      Testing *
      Yes, tested, as reported above.

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      Yes, as above.