Measures: Process & Outcome
Measures collected for the NYS Sepsis Improvement Initiative consist of process and outcome measures (i.e, risk adjusted mortality rates).
Process measure details are provided in the measure specifications, which are available for each year of sepsis data collection. Measures Specifications contains the algorithm/calculation used in deriving the rates for measures/bundles in quarterly hospital reports. For different calendar years, different specification documents are listed; therefore, you will want to review the measure specifications for the discharge timeframe under review.
Measures Specifications beginning in 2017 have been fairly closely aligned with CMS. For all measures, the variables and their associated reported values from the Data Dictionary are used. Please note that different measures may have different exclusions/denominators. Not all cases are included in all measures/bundles. For measures initial lactate administration, blood culture collection and antibiotics administration, the denominators are the same: cases not excluded within 3-hour of Severe Sepsis/Septic Shock. These three measures together are the 3-hour bundle.
For measures repeat lactate administration, crystalloid fluid administration, vasopressor administration and fluid assessment, the exclusions/denominators are different, since not all of these measures are applicable to all cases. Details are presented in the Measures Specifications. These measures, in combination with the 3-hour bundle, comprise the composite bundle.