| eCQM Title | Unexpected Complications in Term Newborns |
||
|---|---|---|---|
| CMS ID | 851 | eCQM Version Number | 6.1.000 |
| CBE Number | Not Applicable | GUID | 8d0fb14f-d3a5-47d3-a78c-52b8f45d296d |
| Measurement Period | January 1, 2026 through December 31, 2026 | ||
| Measure Steward | The Joint Commission | ||
| Measure Developer | The Joint Commission | ||
| Endorsed By | None | ||
| Description |
This measure assesses the unexpected complications among full term newborns with no preexisting conditions (California Maternal Quality Care Collaborative (CMQCC), n.d.). Severe complications include neonatal death, transfer to another hospital for higher level of care, severe birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and infectious complications such as sepsis. Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list for severe e.g., use of continuous positive airway pressure (CPAP) or bone fracture. Examples include less severe respiratory complications e.g., Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants who have a prolonged length of stay of over 5 days. |
||
| Copyright |
Measure specifications are in the Public Domain. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved. |
||
| Disclaimer |
These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. |
||
| Measure Scoring | Proportion | ||
| Measure Type | Outcome | ||
| Stratification |
Stratification 1 - Severe Complications Stratification 2 - Moderate Complications |
||
| Risk Adjustment |
None |
||
| Rate Aggregation |
Aggregate rate generated from count data reported as a rate per 1000 live births. Overall performance rate = (Number of encounters in Numerator / (Number of encounters in Denominator – Number of encounters in Denominator Exclusions)) * 1000 Stratification 1 = (Number of encounters with severe complications / (Number of encounters in Denominator – Number of encounters in Denominator Exclusions)) * 1000 Stratification 2 = (Number of encounters with moderate complications / (Number of encounters in Denominator – Number of encounters in Denominator Exclusions)) * 1000 |
||
| Rationale |
The most important childbirth outcome for families is bringing home a healthy baby. While there have been measures developed to assess clinical practices and outcomes in preterm infants, there is a lack of metrics that assess the health outcomes of term infants who represent over 90% of all births. This measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without preexisting conditions (Fleischman, Oinuma, & Clark, 2010; Reddy et al., 2011; Spong, 2013). This measure also uses length of stay (LOS) modifiers to guard against overcoding and undercoding of diagnoses. Importantly, this metric also serves as a balancing measure for other maternal measures such as Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean rates and early elective delivery rates. The purpose of a balancing measure is to guard against any unanticipated or unintended consequences of quality improvement activities for these measures. |
||
| Clinical Recommendation Statement |
The birth of a baby is the most common reason for hospitalization in the United States and accounts for over half of all hospital admissions. Since childbirth comprises such a large portion of US hospital care, the quality of health care delivered to mothers and their babies should be a focal point for hospitals and health care providers. This hospital level performance metric captures and quantifies neonatal morbidity while accounting for severity of the condition, delivery route (vaginal or cesarean) and neonatal length of stay. There are significant opportunities to improve care for healthy term infants (Russo & Andrews, 2009). Labor, birth management and delivery type can lead to birth injuries, trauma, respiratory complications, hypoxia/asphyxia events and neurologic complications. The ability to evaluate trends and risks across the spectrum of term gestation is limited for mortality and morbidity. This measure addresses this gap by capturing and quantifying severe and moderate neonatal morbidities in term infants that could possibly be reduced or prevented by modifying obstetric and neonatal care practices at the hospital level. |
||
| Improvement Notation |
Decreased score indicates improvement |
||
| Reference |
Reference Type: Citation Reference Text: ''Russo, C.A., & Andrews, R.M. (2009). Potentially avoidable injuries to mothers and newborns during childbirth, 2006. HCUP Statistical Brief Number 74. Rockville, MD. Agency for Healthcare Research and Quality. Retrieved from https://hcup-us.ahrq.gov/reports/statbriefs/sb74.pdf' |
||
| Reference |
Reference Type: Citation Reference Text: 'American College of Obstetricians and Gynecologists. Operative Vaginal Delivery. (2020). Practice Bulletin, Number 219. Obstetrics and Gynecology, 135(4), e149–e159. https://doi.org/10.1097/AOG.0000000000003764' |
||
| Reference |
Reference Type: Citation Reference Text: 'California Maternal Quality Care Collaborative (CMQCC). (n.d.). Unexpected complications in term newborns. Retrieved on May 1, 2025, from https://www.cmqcc.org/focus-areas/quality-metrics/unexpected-complications-term-newborns' |
||
| Reference |
Reference Type: Citation Reference Text: 'Clark, S. L., Miller, D. D., Belfort, M. A., Dildy, G. A., Frye, D. K., & Meyers, J. A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics and Gynecology, 200(2), 156.e1–156.e1564. https://doi.org/10.1016/j.ajog.2008.08.068' |
||
| Reference |
Reference Type: Citation Reference Text: 'Fleischman, A. R., Oinuma, M., & Clark, S. L. (2010). Rethinking the definition of "term pregnancy". Obstetrics and gynecology, 116(1), 136–139. https://doi.org/10.1097/AOG.0b013e3181e24f28' |
||
| Reference |
Reference Type: Citation Reference Text: 'Gregory, K. D., Fridman, M., Shah, S., & Korst, L. M. (2009). Global measures of quality- and patient safety-related childbirth outcomes: should we monitor adverse or ideal rates. American Journal of Obstetrics and Gynecology, 200(6), 681.e1–681.e6817. https://doi.org/10.1016/j.ajog.2009.02.033' |
||
| Reference |
Reference Type: Citation Reference Text: 'Hansen, A. K., Wisborg, K., Uldbjerg, N., & Henriksen, T. B. (2008). Risk of respiratory morbidity in term infants delivered by elective cesarean section: cohort study. British Medical Journal, 336(7635), 85–87. https://doi.org/10.1136/bmj.39405.539282.BE' |
||
| Reference |
Reference Type: Citation Reference Text: 'Martin, J. A., Hamilton, B. E., Ventura, S. J., Osterman, M. J., Wilson, E. C., & Mathews, T. J. (2012). Births: final data for 2010. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 61(1), 1–72.' |
||
| Reference |
Reference Type: Citation Reference Text: 'Practice Bulletin No 178: Shoulder Dystocia. (2017). Obstetrics and Gynecology, 129(5), e123–e133. https://doi.org/10.1097/AOG.0000000000002043' |
||
| Reference |
Reference Type: Citation Reference Text: 'Profit, J., Zupancic, J. A., Gould, J. B., & Petersen, L. A. (2007). Implementing pay-for-performance in the neonatal intensive care unit. Pediatrics, 119(5), 975–982. https://doi.org/10.1542/peds.2006-1565' |
||
| Reference |
Reference Type: Citation Reference Text: 'Puopolo, K.M., Lynfield, R., & Cummings, J.J., & American Academy of Pediatrics, Committee on Fetus and Newborn, Committee on Infectious Diseases. (2019). Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics, 144 (2). https://doi.org/10.1542/peds.2019-1881' |
||
| Reference |
Reference Type: Citation Reference Text: 'Reddy, U. M., Bettegowda, V. R., Dias, T., Yamada-Kushnir, T., Ko, C. W., & Willinger, M. (2011). Term pregnancy: a period of heterogeneous risk for infant mortality. Obstetrics and gynecology, 117(6), 1279–1287. https://doi.org/10.1097/AOG.0b013e3182179e28' |
||
| Reference |
Reference Type: Citation Reference Text: 'Spong, C.Y. (2013, June 19). Defining “Term” pregnancy: recommendations from the defining “Term” pregnancy workgroup. Journal of the American Medical Association, 309(23), 2445-2446. https://doi.org/10.1001/jama.2013.6235' |
||
| Reference |
Reference Type: Citation Reference Text: 'Tita, A.T., Landon, M.B., Spong, C.Y., Lai, Y., Leveno, K.J., Varner, M.W., . . . Mercer, B.M. (2009). Timing of elective repeat cesarean delivery at term and neonatal outcomes. New England Journal of Medicine, 360(2), 111-120. https://doi.org/10.1056/NEJMoa0803267' |
||
| Reference |
Reference Type: Citation Reference Text: 'Wilmink, F. A., Hukkelhoven, C. W., Lunshof, S., Mol, B. W., van der Post, J. A., & Papatsonis, D. N. (2010). Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American Journal of Obstetrics and Gynecology, 202(3), 250.e1–250.e2508. https://doi.org/10.1016/j.ajog.2010.01.052' |
||
| Reference |
Reference Type: Citation Reference Text: 'Zhang, X., & Kramer, M.S. (2009). Variations in mortality and morbidity by gestational age among infants born at term. Journal of Pediatrics, 154, 358-362. https://doi.org/10.1016/j.jpeds.2008.09.013' |
||
| Definition |
None |
||
| Guidance |
A discharge to a designated cancer center or children's hospital should be captured as a discharge to an acute care facility. Data show that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in the electronic health record (EHR) system. Only one birth weight value should be recorded. In cases where there is conflicting data, use the document recording the birth weight closest to the start of encounter. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
||
| Transmission Format |
TBD |
||
| Initial Population |
Inpatient hospitalization for single newborns who were born in the hospital with a discharge date during the measurement period and with either of the following conditions: - Gestational age at birth of >=37 weeks - Birth weight 3000 grams or more without gestational age at birth |
||
| Denominator |
Equals Initial Population |
||
| Denominator Exclusions |
Inpatient hospitalization for newborns who were born with congenital malformations and genetic diseases, pre-existing fetal conditions, or maternal drug use exposure in-utero |
||
| Numerator |
Inpatient hospitalization for newborns with severe or moderate complications:
Severe Complications as any of the following conditions -
- Discharge status of patient expired
- Discharged to an acute care facility (ACF) or other health care facility (HCF) with severe complications or without any complications
- Severe morbidities diagnoses, including:
- Neonatal severe birth trauma
- Neonatal severe hypoxia or asphyxia
- Neonatal severe shock and resuscitation
- Neonatal severe respiratory complications
- Neonatal severe infection
- Neonatal severe neurological complications
- Severe morbidities procedures, including:
- Neonatal severe shock and resuscitation procedures
- Neonatal severe respiratory procedures
- Neonatal severe neurological procedures
- Severe septicemia with length of stay more than 4 days or discharged to an ACF or other HCF
Moderate Complications as any of the following conditions -
- Moderate complications diagnoses, including:
- Neonatal moderate birth trauma
- Neonatal moderate respiratory complications
- Moderate complications procedures, including:
- Neonatal moderate respiratory complications procedures
- Vaginal delivery with length of stay more than 2 days OR cesarean birth with length of stay more than 4 days, who have any of the following moderate length of stay complications:
- Moderate complications diagnoses, including:
- Neonatal moderate birth trauma
- Neonatal moderate respiratory complications
- Neonatal moderate infection
- Moderate complications procedures, including:
- Neonatal moderate neurological complications procedures
- Neonatal moderate respiratory complications procedures
- Discharged to an ACF or other HCF, who have any moderate length of stay complications
- Length of stay more than 5 days without jaundice and social indications
|
||
| Numerator Exclusions |
None |
||
| Denominator Exceptions |
None |
||
| Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity, and sex |
||
PCNewborn."Single Live Term Newborn Encounter"
"Initial Population"
"Single Live Term Newborn Encounter With Congenital Malformation Or Fetal Conditions Or Maternal Drug Use"
"Single Live Term Newborn Encounter With Severe Complications"
union "Single Live Term Newborn With Discharge To Acute Care Or Other Health Care Facility Without Any Complications Coded"
union "Single Live Term Newborn Encounter With Moderate Complications Or Length Of Stay Criteria Met"
None
None
"Stratification Encounter"
intersect ("Single Live Term Newborn Encounter With Severe Complications"
union "Single Live Term Newborn With Discharge To Acute Care Or Other Health Care Facility Without Any Complications Coded"
)
"Stratification Encounter"
intersect "Single Live Term Newborn Encounter With Moderate Complications Or Length Of Stay Criteria Met"
"Initial Population"
"Single Live Term Newborn Encounter With Congenital Malformation Or Fetal Conditions Or Maternal Drug Use"
PCNewborn."Single Live Term Newborn Encounter"
["Procedure, Performed": "Neonatal Moderate Respiratory Complications Procedures"]
["Procedure, Performed": "Phototherapy"]
["Procedure, Performed": "Neonatal Moderate Respiratory complications with LOS Procedures"]
"Single Live Term Newborn Encounter With Severe Complications"
union "Single Live Term Newborn With Discharge To Acute Care Or Other Health Care Facility Without Any Complications Coded"
union "Single Live Term Newborn Encounter With Moderate Complications Or Length Of Stay Criteria Met"
["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
where exists ( InpatientEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Single Live Born Newborn Born in Hospital"
)
and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
"Single Live Birth Encounter" SingleLiveBornEncounter
without ["Assessment, Performed": "Gestational age--at birth"] GestationalAge
such that Global."EarliestOf" ( GestationalAge.relevantDatetime, GestationalAge.relevantPeriod ) during SingleLiveBornEncounter.relevantPeriod
and GestationalAge.result is not null
where "FirstBirthWeight"(SingleLiveBornEncounter)>= 3000 'g'
"Single Live Birth Encounter" SingleLiveBornEncounter
with ["Assessment, Performed": "Gestational age--at birth"] GestationalAge
such that GestationalAge.result >= 37 weeks
and Global."EarliestOf" ( GestationalAge.relevantDatetime, GestationalAge.relevantPeriod ) during SingleLiveBornEncounter.relevantPeriod
( "Single Live Birth Encounter With Gestational Age 37 Weeks Or More"
union "Single Live Birth Encounter With Birth Weight 3000 Grams Or More Without Gestational Age"
)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "Federal Administrative Sex"]
["Procedure, Performed": "Neonatal Severe Shock and Resuscitation Procedures"]
union ["Procedure, Performed": "Neonatal Severe Respiratory Procedures"]
union ["Procedure, Performed": "Neonatal Severe Neurological Procedures"]
( PCNewborn."Single Live Term Newborn Encounter"
except "Single Live Term Newborn Encounter With Moderate Complications"
except "Single Live Term Newborn Encounter With Moderate Complications By Cesarean Birth With Length Of Stay More Than 4 Days Or By Vaginal Birth With Length Of Stay More Than 2 Days" ) QualifyingEncWithExceptions
where not ( exists ( QualifyingEncWithExceptions.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Neonatal Jaundice"
or EncounterDiagnoses.code in "Social Indications"
)
or exists ( "Moderate Complication Procedures For Jaundice" JaundiceProcedure
where Global."NormalizeInterval" ( JaundiceProcedure.relevantDatetime, JaundiceProcedure.relevantPeriod ) starts during day of QualifyingEncWithExceptions.relevantPeriod
)
)
and Global."LengthInDays" ( QualifyingEncWithExceptions.relevantPeriod ) > 5
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Congenital Malformations"
or EncounterDiagnoses.code in "Fetal Conditions"
or EncounterDiagnoses.code in "Maternal Drug Use"
)
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists (QualifyingEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Neonatal Moderate Birth Trauma"
or EncounterDiagnoses.code in "Neonatal Moderate Respiratory Complications"
)
or exists ("Moderate Complication Procedures" ModerateComplicationProcedure
where Global."NormalizeInterval" ( ModerateComplicationProcedure.relevantDatetime, ModerateComplicationProcedure.relevantPeriod ) starts during day of QualifyingEncounter.relevantPeriod
)
or ((QualifyingEncounter.dischargeDisposition in "Discharge To Acute Care Facility"
or QualifyingEncounter.dischargeDisposition in "Other Health Care Facility")
and "HasModerateLengthOfStayComplications"(QualifyingEncounter) //Discharged to an ACF or other HCF with moderate complications LOS codes will satisfy moderate complications regardless of LOS
)
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
where (( EncounterDiagnoses.code in "Single Liveborn Newborn Cesarean"
and Global."LengthInDays" ( QualifyingEncounter.relevantPeriod ) > 4
)
or ( EncounterDiagnoses.code in "Single Liveborn Newborn Vaginal"
and Global."LengthInDays" ( QualifyingEncounter.relevantPeriod ) > 2
)
)
)
and "HasModerateLengthOfStayComplications"(QualifyingEncounter)
( "Single Live Term Newborn Encounter With Moderate Complications"
union "Single Live Term Newborn Encounter With Moderate Complications By Cesarean Birth With Length Of Stay More Than 4 Days Or By Vaginal Birth With Length Of Stay More Than 2 Days"
union "Single Live Term Newborn Encounter Length Of Stay More Than 5 Days Without Jaundice And Social Indications"
)
except ("Single Live Term Newborn Encounter With Severe Complications" union "Single Live Term Newborn With Discharge To Acute Care Or Other Health Care Facility Without Any Complications Coded")
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where QualifyingEncounter.dischargeDisposition in "Patient Expired"
or QualifyingEncounter.dischargeDisposition in "Discharged to Health Care Facility for Hospice Care"
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where ( exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Neonatal Severe Septicemia"
)
)
//Discharged to an ACF or other HCF will satisfy severe complications regardless of LOS
and (Global."LengthInDays" ( QualifyingEncounter.relevantPeriod ) > 4
or QualifyingEncounter.dischargeDisposition in "Discharge To Acute Care Facility"
or QualifyingEncounter.dischargeDisposition in "Other Health Care Facility"
)
"Single Live Term Newborn Encounter With Selected Discharge Disposition"
union "Single Live Term Newborn Encounter With Severe Morbidities"
union "Single Live Term Newborn Encounter With Sepsis And Length Of Stay More Than 4 Days Or Discharged To An ACF Or Other HCF"
PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
where exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
where EncounterDiagnoses.code in "Neonatal Severe Birth Trauma"
or EncounterDiagnoses.code in "Neonatal Severe Hypoxia or Asphyxia"
or EncounterDiagnoses.code in "Neonatal Severe Shock and Resuscitation"
or EncounterDiagnoses.code in "Neonatal Severe Respiratory Complications"
or EncounterDiagnoses.code in "Neonatal Severe Infection"
or EncounterDiagnoses.code in "Neonatal Severe Neurological Complications"
)
or exists ( "Severe Complication Procedures" SevereComplicationProcedure
where Global."NormalizeInterval" ( SevereComplicationProcedure.relevantDatetime, SevereComplicationProcedure.relevantPeriod ) starts during day of QualifyingEncounter.relevantPeriod
)
(PCNewborn."Single Live Term Newborn Encounter" QualifyingEncounter
except "Single Live Term Newborn Encounter With Severe Complications"
except "Single Live Term Newborn Encounter With Moderate Complications"
except "Single Live Term Newborn Encounter With Moderate Complications By Cesarean Birth With Length Of Stay More Than 4 Days Or By Vaginal Birth With Length Of Stay More Than 2 Days") QualifyingEncWithoutComplications
where QualifyingEncWithoutComplications.dischargeDisposition in "Discharge To Acute Care Facility"
or QualifyingEncWithoutComplications.dischargeDisposition in "Other Health Care Facility"
// Define a Stratification Encounter to exclude any numerator encounters that also satisfies denominator exclusion criteria.
"Numerator"
except "Denominator Exclusions"
"Stratification Encounter"
intersect ("Single Live Term Newborn Encounter With Severe Complications"
union "Single Live Term Newborn With Discharge To Acute Care Or Other Health Care Facility Without Any Complications Coded"
)
"Stratification Encounter"
intersect "Single Live Term Newborn Encounter With Moderate Complications Or Length Of Stay Criteria Met"
if ( HasStart(period)) then start of period
else
end of period
Earliest(NormalizeInterval(pointInTime, period))
not ( start of period is null
or start of period = minimum DateTime
)
difference in days between start of Value and end of Value
if pointInTime is not null then Interval[pointInTime, pointInTime]
else if period is not null then period
else null as Interval<DateTime>
exists (Encounter.diagnoses EncounterDiagnosesLOS
where EncounterDiagnosesLOS.code in "Neonatal Moderate Birth Trauma with LOS"
or EncounterDiagnosesLOS.code in "Neonatal Moderate Respiratory Complications with LOS"
or EncounterDiagnosesLOS.code in "Neonatal Moderate Infection with LOS"
)
or exists ( ["Diagnostic Study, Performed": "Neonatal Moderate Neurological Complications with LOS Procedures"] ModerateNeuroProcedureLOS
where Global."NormalizeInterval" ( ModerateNeuroProcedureLOS.relevantDatetime, ModerateNeuroProcedureLOS.relevantPeriod ) starts during Encounter.relevantPeriod
)
or exists ( "Moderate Complication Procedures With LOS" ModerateProcedureLOS
where Global."NormalizeInterval" ( ModerateProcedureLOS.relevantDatetime, ModerateProcedureLOS.relevantPeriod ) starts during day of Encounter.relevantPeriod
)
First(["Assessment, Performed": "Birth Weight"] BirthWeight
where Global."EarliestOf"(BirthWeight.relevantDatetime, BirthWeight.relevantPeriod)during Encounter.relevantPeriod
and BirthWeight.result is not null
sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
).result as Quantity
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "Federal Administrative Sex"]
| Measure Set |
eMeasure Perinatal Care (ePC) |
||
|---|---|---|---|