Surgery

Hospital specific risk-adjusted measure of mortality or one or more of the following major complications (cardiac arrest, myocardial infarction, CVA/stroke, on ventilator >48 hours, acute renal failure (requiring dialysis), bleeding/transfusions, graft/prosthesis/flap failure, septic shock, sepsis, and organ space surgical site infection), within 30 days of a lower extremity bypass (LEB) in patients age 16 and older.

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) following elective primary THA and/or TKA in Medicare Fee-For-Service (FFS) beneficiaries who are 65 years and older. The outcome (readmission) is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission (the admission included in the measure cohort). A specified set of planned readmissions do not count in the readmission outcome.

The percentage of home health episodes of care during which the patient demonstrates an improvement in the condition of surgical wounds.

Percentage of patients undergoing elective endovascular repair of asymptomatic infrarenal abdominal aortic aneurysms (AAA) who die while in hospital. This measure is proposed for both hospitals and individual providers. The measure is currently reported in the Vascular Quality Initiative (VQI) Registry.

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Categories, a multi-institutional validated risk stratification tool

In-hospital deaths per 1,000 discharges with pancreatic resection, ages 18 years and older. Includes metrics for discharges grouped by type of diagnosis and procedure. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.
[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

The number of hospital discharges with a procedure of partial or total pancreatic resection for patients 18 years and older or obstetric patients. Excludes acute pancreatitis admissions.

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases per 1,000 elective surgical discharges for patients ages 18 years and older.