Measure Description
Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.
Denominator
Patients, aged 18 years and older, undergoing elective total joint arthroplasty.
Denominator Note: For the purpose of this measure, total joint arthroplasty includes arthroplasty of the knee, hip, and shoulder.
Denominator Criteria (Eligible Cases):All patients, aged 18 years and olderANDElective Surgery: G9643ANDPatient encounter during the reporting period (CPT): 01214, 01215, 01402, 01638
Denominator ExclusionsSurgeon or other non-anesthesia professional clinician completed one or more of the management strategies without direction or assistance from the anesthesia professional.
Numerator
Patients who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.
Management strategies include one or more of the following:
- Cell salvage techniques employed intraoperatively
- Intraoperative antifibrinolytic therapy or tourniquet, if not contraindicated
- Preoperative iron supplementation, epoetin alpha
- Use of evidence-based preoperative anemia management algorithm supplemented with laboratory testing and/or multidisciplinary consult
Numerator definition: For the purpose of this measure, a positive preoperative anemia screening result is defined as a Hgb value <13 gm/dL for men or Hgb value <12 gm/dL for women
Numerator note: Preoperative screening for anemia could include any of the following tests: complete blood count (CBC), arterial blood gas (ABG), venous blood gas (VBG), or other point of care hemoglobin/hematocrit test within 90 days and until one day prior to the surgical procedure.
Numerator Quality-Data Coding Options for Reporting SatisfactorilyPerformance Met:11A67 Patient was screened for anemia preoperatively AND documentation of one or more selected management strategies used prior to PACU discharge.ORDenominator Exception:11A68 Negative preoperative anemia screening result.ORDenominator Exception:11A69 Documentation of medical or patient reason(s) for not screening for anemia and/or using selected management strategies (e.g., Jehovah’s witness,patient refusal, contraindication, etc).ORPerformance Not Met:11A70 No preoperative patient screen for anemia OR positive preoperative anemia screening result and no documentation of one or more selected management strategies used prior to PACU discharge.
Numerator Exclusions
None
NQF ID Number
N/A
NQS Domain
Patient Safety
High Priority Measure
Yes
Includes Telehealth?
No
Inverse Measure
No
Proportional Measure
Yes
Continuous Variable Measure
No
Ratio Measure
No
Number of performance rates to be calculated and submitted
1
Risk-Adjusted Status?
No
Meaningful Measure
Preventable Healthcare Harm
Measure Type
Process
Care Settings
Hospital