AIM Data Reporting Measures v1.5
Universal AIM Data Measures
Outcomes Measures (O): State
Report Quarterly
O1: Severe Maternal Morbidity
Numerator: Cases with any SMM code (see SMM Indicator Codes by Categories)
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages
Note: All SMM Outcome Measures will also be calculated by major race/ethnicity
strata White, Black,, Other-Other maybe subdivided if there are additional categories
that are a significant proportion such as Native American)
Numerator: Cases with any SMM code, exclude transfusions (99.x) (see SMM
Indicator Codes by Categories)
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages
O2: Severe Maternal Morbidity
(excluding transfusions)
Process Measures (P): Birth Facility
P1: Unit Drills
Report Quarterly


How many drills were performed on your unit in this quarter for any
maternal safety topic?
What topics were covered in the drills this quarter? Drill Topic selections
include: Obstetric Hemorrhage, Severe Hypertension/Preeclampsia, Other
Report # of drills and drill topics.
Structure Measures (S): Birth Facility
Report once
S1: Patient, Family & Staff Support
Has your hospital developed OB specific resources and protocols to support patients,
family and staff through major OB complications?
Report completion date
Has your hospital established a system in your hospital to perform regular formal
debriefs after cases with major complications?
Note: Major complications will be defined by each facility based on volume, but is
meant to include more than cases with ICU admissions and with ≥ 4 units RBC
transfusions.
Report start date
Has your hospital established a process to perform multidisciplinary systems-level
reviews on all cases of severe maternal morbidity (including women admitted to the
ICU or receiving ≥4 units RBC transfusions)?
Report start date
S2: Debriefs
S3: Multidisciplinary Case Reviews
Obstetric Hemorrhage
Outcomes Measures (O): State
Report Quarterly
O1: Severe Maternal Morbidity
O2: Severe Maternal Morbidity (excluding
transfusions)
O3: Severe Maternal Morbidity among
Hemorrhage Cases
Universal AIM Data Measure
Universal AIM Data Measure
O4: Severe Maternal Morbidity (excluding
transfusion) among Hemorrhage Cases
Numerator: Cases with a SMM code (see SMM Indicator Codes by Categories)
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages, with one of the following codes:
 Abruption, Previa or Antepartum hemorrhage: 641.20, 642.21, 641.23
 Transfusion: 99.00, 99.03, 99.04 (exclude transfusion codes for women with
Sickle Cell Disease-282.6x)
 Postpartum hemorrhage: 666.xx
Numerator: Cases with a SMM code, exclude transfusions (99.x)
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages, with one of the following codes:
 Abruption, Previa or Antepartum hemorrhage: 641.20, 642.21, 641.23
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AIM Data Reporting Measures v1.5

Postpartum hemorrhage: 666.xx
Process Measures (P): Birth Facility
Report Quarterly
P1: Unit Drills
P2: Provider Education
Universal AIM Data Measure
What cumulative proportion of obstetric physicians and midwives have completed
an education program on hemorrhage (within the last 2 years) that includes
teaching on the Hemorrhage bundle and the unit-standard protocol?
Report estimate in 10% increments
What cumulative proportion of OB nurses have completed an education program on
hemorrhage (within the last 2 years) that includes teaching on the Hemorrhage
bundle and the unit-standard protocol?
Report estimate in 10% increments.
Report estimate in 10% increments
What proportion of women who gave birth during this quarter had a hemorrhage
risk assessment recorded in the medical record prior to them giving birth?
Report estimate in 10% increments.
Report estimate in 10% increments
What proportion of women who gave birth had formal measurement of cumulative
blood loss from the time they gave birth through the recovery period recorded in
the medical record during this quarter?
Report estimate in 10% increments.
Report estimate in 10% increments
P3: Nursing Education
P4: Risk Assessment
P5: Quantified Blood Loss
Structure Measures (S): Birth Facility
Report once
S1: Patient, Family, & Staff Support
S2: Debriefs
S3: Multidisciplinary Case Reviews
S4: Hemorrhage Supplies
Universal AIM Data Measure
Universal AIM Data Measure
Universal AIM Data Measure
Does your hospital have OB hemorrhage supplies readily available?
Report completion date.
Does your hospital have an up-to-date OB hemorrhage policy and procedure
(reviewed and updated in the last 2-3 years) that Provides a unit-standard approach using a stage-based management plan
with checklists
 Ensures availability to OB hemorrhage supplies at all times
Report completion date
Were the recommended OB hemorrhage bundle processes (i.e. order sets, tracking
tools) integrated into your hospital’s Electronic Health Record system?
Report completion date.
Report completion date.
S5: Unit Policy and Procedure
S6: EHR Integration
Severe Hypertension (HTN)/Preeclampsia
Outcomes Measures (O): State
Report Quarterly
O1: Severe Maternal Morbidity
O2: Severe Maternal Morbidity
(excluding transfusions)
O3: Severe Maternal Morbidity Among
Preeclampsia Cases
Universal AIM Data Measure
Universal AIM Data Measure
Numerator: Cases with a SMM code
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages, with one of the following codes:
 Severe Preeclampsia 642.5x
 Eclampsia 642.6x
 Preeclampsia superimposed on pre-existing hypertension 642.7x
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AIM Data Reporting Measures v1.5
O4: Severe Maternal Morbidity
(excluding transfusion) Among
Preeclampsia Cases
Numerator: Cases with a SMM code, exclude transfusions (99.x)
Denominator: All mothers during their birth admission, exclude ectopics and
miscarriages, with one of the following codes:
 Severe Preeclampsia 642.5x
 Eclampsia 642.6x
 Preeclampsia superimposed on pre-existing hypertension 642.7x
Process Measures (P): Birth Facility
Report Quarterly
P1: Unit Drills
P2: Provider Education
Universal AIM Data Measure
What cumulative proportion of obstetric physicians and midwives have completed an
education program on Preeclampsia (within the last 2 years) that includes teaching
on the Severe HTN/Preeclampsia bundle and the unit-standard protocol?
Report estimate in 10% increments
What cumulative proportion of OB nurses have completed education on Severe
HTN/Preeclampsia (within the last 2 years) that includes teaching on the Severe
HTN/Preeclampsia bundle and the unit-standard protocol?
Report estimate in 10% increments
Numerator: Proportion of women with persistent new-onset severe HTN (Systolic:
>160 or Diastolic: >110) who were treated within 1 hour (excludes women with an
exacerbation of chronic HTN)
Denominator: Use at least two systems for identification of denominator cases.
Treatment may include IV Labetalol, IV Hydralazine, or PO Nifedipine.
Report N/D
P3: Nursing Education
P4: Treatment of Severe HTN
Structure Measures (S): Birth Facility
Report
S1: Patient, Family, Staff Support
S2: Debriefs
S3: Multidisciplinary Case Reviews
S4: Unit Policy and Procedure
Universal AIM Data Measure
Universal AIM Data Measure
Universal AIM Data Measure
Does your hospital have an up-to-date Severe HTN/Preeclampsia policy and
procedure (reviewed and updated in the last 2-3 years) that provides a unit-standard
approach to measuring blood pressure, treatment of Severe HTN/Preeclampsia,
administration of Magnesium Sulfate, and treatment of Magnesium Sulfate
overdose?
Report completion date
Were the recommended Severe HTN/Preeclampsia bundle processes (i.e. order sets,
tracking tools) integrated into your hospital’s Electronic Health Record system?
Report completion date
S5: EHR Integration
Severe Maternal Morbidity (SMM) Codes by Categories
SMM Indicator
ICD-9-CM Codes (2015 CDC Code List to States)
1. Acute myocardial infarction
2. Acute renal failure
Diagnosis
Diagnosis
3. Adult respiratory distress syndrome
410.xx
584.x, 669.3x
Note: 277.8 Tumor lysis syndrome is in the CDC SAS code,
but not on the CDC website (Possible typo)
518.5, 518.81, 518.82, 518.84, 799.1
Type
4. Amniotic fluid embolism
5. Aneurysm
673.1x
441.xx
Diagnosis
Diagnosis
6. Cardiac arrest/Ventricular fibrillation
7. Disseminated intravascular coagulation
8. Eclampsia
427.41, 427.42, 427.5
286.6, 286.9, 666.3x
642.6x
Diagnosis
Diagnosis
Diagnosis
Diagnosis
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AIM Data Reporting Measures v1.5
9. Heart failure during procedure or surgery
10. Internal injuries of thorax, abdomen, and pelvis
11. Intracranial injuries
669.4x, 997.1
860.xx-869.xx
800.xx, 801.xx, 803.xx, 804.xx,
851.xx-854.xx
430, 431, 432.x, 433.xx, 434.xx, 436, 437.x, 671.5x, 674.0x,
997.2, 999.2
428.1, 518.4
Diagnosis
Diagnosis
Diagnosis
Diagnosis
Diagnosis
16. Shock
668.0x, 668.1x, 668.2x
038.xx, 995.91, 995.92, 670.2
Note: 670.2 is not on CDC website, but it is in the CDC SAS
code
669.1x, 785.5x, 995.0, 995.4, 998.0
17. Sickle cell anemia with crisis
282.62, 282.64, 282.69
Diagnosis
18. Thrombotic embolism
415.1x, 673.0x, 673.2x, 673.3x, 673.8x
Diagnosis
19. Blood transfusion
20. Cardio monitoring
99.0x
89.6x
Procedure
Procedure
21. Conversion of cardiac rhythm
22. Hysterectomy
99.6x
68.3x-68.9
Procedure
Procedure
23. Operations on heart and pericardium
35.xx, 36.xx, 37.xx, 39.xx
Procedure
24. Temporary tracheostomy
25. Ventilation
31.1
93.90, 96.01-96.05, 96.7x
Procedure
Procedure
12. Puerperal cerebrovascular disorders
13. Pulmonary edema
14. Severe anesthesia complications
15. Sepsis
Diagnosis
Diagnosis
Diagnosis
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