Core measures alqio.indd

Complete and detailed information is available in the Specifi cations Manual located on QualityNet (www.QualityNet.org) under the Hospitals-Inpatient tab.
Core Measures Help Booklet
This material was originally created by IQH, the Medicare Quality Improvement Organization for Mississippi, and distributed by AQAF, the Medicare Quality Improvement Organization for Ala- bama, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents do not necessarily refl ect CMS policy. Immunization - New (Beginning with January, 1 , 2012 discharges)
Aspirin at Discharge:
Pneumococcal Immunization (*PPV23)
Prescribe at discharge or document reason for No aspirin at discharge.
(Includes ALL patients discharged from acute care age 65 years and older AND ages 6 through 64 who are Documentation must clearly indicate aspirin is being prescribed at discharge. considered †high risk and who have a LOS less than or equal to 120 days)
Excludes: Patients less than 6 years of age, who are pregnant or who received an organ transplant this
Coumadin/warfarin or Pradaxa/dabigatran at discharge Other explicitly documented reason by Phys/APN/PA/Pharmacist 1. Screen pts 65 and older and 6 – 64 years of age with a †high risk condition for vaccination status
2. *Vaccinate pt prior to discharge if:
‡Fibrinolytic Therapy: (Fibrinolysis/Reperfusion)
a. Not previously vaccinated (Vaccines noted as “up-to-date” count. Do not use “UTD.”
[If provided w/in 6hrs of hospital arrival & is primary reperfusion therapy]
b. No documented allergy (document exact complication) Clear documentation is important: Applies to pts with ST-segment elevation/LBBB noted on ECG performed c. Not likely to be uneffective due to bone marrow transplant w/in the past 12 months d. No radiation/chemotherapy currently being received as a scheduled dose, received Give w/in 30 min of hospital arrival or *document reason for the delay.
during this stay or within 2 weeks prior to this stay Balloon pump; Cardiopulmonary arrest; Intubation e. No shingles (Zostavax) vaccination received w/in the past 4 weeks [Automatic - If occurred w/in 30 min after hosp arrival] g. For patients 6 years of age or older: Did not receive a conjugate vaccine w/in the past the Other reasons that include BOTH the notation of delay + underlying (non-system) reason ‡Table 4
†6-64 – High risk conditions include: diabetes, nephritic syndrome, ESRD, CHF, COPD, HIV or asplenia
Primary PCI: (PCI/Reperfusion/Cath/Transfer to Cath Lab)
[If performed w/in 24hrs of hospital arrival] - Clear documentation is important: Applies to pts with ST-
†19-64 – Include the high risk condition of asthma in addition to the above
segment elevation/LBBB noted on ECG performed closest to arrival. * For high-risk children 6-18 years of age may include either PCV13 or PPV23 as this population
Perform w/in 90 min of hospital arrival or *document reason for delay.
should receive PCV13 prior to PPV23
Balloon pump; Cardiopulmonary arrest; Intubation [Automatic - If occurred w/in 90 min after hosp arrival] Infl uenza Immunization
(Includes ALL patients discharged from acute care age 6 months and older AND who have a LOS less than or Other reasons that include BOTH the notation of delay + underlying (non-system) reason Excludes: Patients less than 6 months of age or who received an organ transplant this hospitalization.
‡Statin (or HMG CoA reductase inhibitors) Prescribed at Discharge:
Prescribe at discharge or document reason for No statin at discharge.
*1. Screen pts 6 months and older during current fl u season (when vaccine is available - March) for vaccina-
tion status. *Hospital is only responsible for collection during discharges Oct - March.
Documentation must clearly indicate the medication (listed by name) is being prescribed at discharge. Allergy to or complication related to statins 2. Vaccinate pt prior to discharge if:
Other explicitly documented reason by Phys/APN/PA/Pharmacist, i.e., statins contrain- a. Not previously vaccinated this fl u season b. No documented allergy to infl uenza vaccine; anaphylactic latex allergy or anaphylatic allergy to eggs (document exact complication) c. Not likely to be uneffective due to bone marrow transplant w/in the past 6 months d. No documented Guillian-Barre’ syndrome w/in 6 weeks after previous infl uenza (**More common reasons. Must be linked to no statins prescribed.) ‡Table 5
Excludes: Patients with an LDL < 100 mg/dL [either direct or calculated] w/in 24hrs after hospital arrival or 30
days prior to hospital arrival and not discharged on a statin.
Special Note: Comfort Measures Only excludes cases from all measures except lytic and PCI.
ED Throughput - New (Beginning with January, 1 , 2012 discharges)
Median Time from ED Arrival to ED Departure for Admitted ED Patients:
Beginning with January 2012, the following measures were retired or suspended. (Includes ALL patients discharged from acute care AND with a LOS less than or equal to 120 days) There are several reasons measures are retired: 1. Measure performance among hospitals is so high and unvarying that meaningful distinctions and Excludes: Patients who are not *ED patients
improvements in performance can no longer be made; Performance or improvement on a measure does not result in better patient outcomes; Document in the ED Record the date and time when the patient physically left the ED. (Don’t use disposittion
A measure does not align with current clinical guidelines or practice; date/time, the time the discharge order was written, or the report called time.) Emphasis is placed on captur-
There is the availability of a more broadly applicable measure for the topic; ing the latest time the patient was receiving care in the ED, under ED services or awaiting transport.
There is the availability of a measure that is more proximal in time to desired patient outcomes for the There is the availability of a measure that is more strongly associated with desired patient outcomes for the Admit Decision Time to ED Departure Time for Admitted Patients:
(Includes ALL patients discharged from acute care AND with a LOS less than or equal to 120 days) Collection or public reporting of a measure leads to negative unintended consequences other than patient harm.
Excludes: Patients who are not *ED patients
The one retired measure, Adult Smoking Cessation Advice/Counseling, is considered “topped out,” indicating that
Document in the ED Record the date and time the decision was made to admit the patient to the hospital as
nationally, it has met and maintained a very high performance level, with little or no room for improvement. Also, an inpatient. (The admit or disposition order date/time may be used). Emphasis is placed on when the
screening should apply to ALL patients, not just those with AMI. No data will be collected or reported on this AMI (earliest) decision was communicated.
The suspended measures are those which CMS is considering retiring; however, due to public concern over
Document in the ED Record the date and time when the patient physically left the ED. (Don’t use disposittion
possible declination of adherence, data collection and submission may be continued and any data submitted will be date/time, the time the discharge order was written, or the report called time.) Emphasis is placed on captur-
publically reported on Hospital Compare.
ing the latest time the patient was receiving care in the ED, under ED services or awaiting transport.

Because these measures are still considered “best practices” and indicators of high quality, they will
* ED Patient is defi ned as any patient receiving care or services in the Emergency Department.
continue to be a part of this Core Measures Help Booklet.
Aspirin at Arrival: [Suspended]
Under ED Services: Use the time patients depart from observation services.
Give w/in 24hrs before or after arrival or document reason for No aspirin on arrival.
If admitted to an observation unit of the ED, use the time they departed the observation unit. If placed into observation services but remains in the ED or ED unit, use the time they departed the ED or Note regarding 24 hrs prior to arrival: For patients received as transfers, documentation must be clear that ASA ED unit for the fl oor/surgery, etc.; not the time they are placed into observation.
was received within 24 hours of arrival or was a current medication at the transferring facility.
Outside the services of the ED: Use the time of departure from the ED. Pre-arrival Coumadin/warfarin or Pradaxa/dabigatran If patient is placed into observation but remains in the ED or ED unit, use the time they departed the ED Other explicitly documented reason by Phys/PA/APN/Pharmacist or ED unit for the fl oor/surgery, etc.; not the time they are placed into observation.
** Observation Services: Services furnished by a hospital on the hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for possible admission to the hospital as an inpatient.
Improvement noted as: A decrease in the median value.
VTE - Recommended Prophylaxis (Table 12)
‡ACEI/ARB at Discharge for LVSD: [Suspended] (Includes RAS/RAAS blockers/inhibitors)
Prescribe EITHER at discharge for pts with < 40% EF or moderate/severe LVSD; or document reason for
Recommend Prophylaxis
No ACEI AND No ARB at discharge.
Elective Total Knee Replacement
‡Tables 1 & 2
Documentation must clearly indicate the medication (listed by name) is being prescribed at discharge. Intermittent pneumatic compression devices (IPC) Moderate or severe aortic stenosis [Counts for BOTH] Other explicitly documented reason by Phys/APN/PA/Pharmacist Hip Fracture Surgery
Phys/APN/PA/Pharmacist documentation that either an ACEI or an ARB was not given due to one of the following 5 conditions [Counts for BOTH]: Elective Total Hip Replacement
with a reason for not administer-
Intermittent pneumatic compression devices (IPC) 5. Worsening renal function/renal disease/dysfunction ing pharmacological prophylaxis
A Conditional Hold with parameters (re: BP) counts as a reason IF there is documenta-
tion that the ACEI/ARB was held due to the specifi ed parameters.
Hip Fracture Surgery with a
reason for not administering phar- •
macological prophylaxis
Intermittent pneumatic compression devices (IPC) Adult Smoking Cessation Advice/Counseling: [Retired]
Give to pts with clear history of cigarette smoking anytime during the past year prior to arrival. Always
inquire.
*The U.S. Food and Drug Administration has approved Xarelto (Rivaroxaban) to reduce the risk of blood clots, deep vein thrombosis (DVT) and pulmonary embolism (PE) following knee or hip replacement surgery ONLY. ‡Beta-Blocker at Discharge: [Suspended]
Note: Patients who receive neuraxial anesthesia or have a documented reason for not administering pharma-
Prescribe at discharge or document reason for No beta-blocker at discharge.
cological prophylaxis may pass the performance measure if either appropriate pharmacological is ordered or mechanical prophylaxis is ordered or placed on pt. Documentation must clearly indicate the medication (listed by name) is being prescribed at discharge. 2nd or 3rd degree heart block on ECG on arrival or during stay w/o pacemaker Other explicitly documented reason [including Bradycardia] by Phys/APN/PN/Phar-
macist
Conditional Hold with parameters (re: HR or BP) counts as a reason IF there is
documentation that the beta-blocker was held due to the specifi ed parameters.
‡Table 3
VTE - Recommended Prophylaxis (Table 12)
AMI/HF - ACEIs (Table 1)
Recommend Prophylaxis
Intracranial Neurosurgery
Intermittent pneumatic compression devices (IPC) with or without graduated compression stockings (GCS) † Current guidelines recommend postoperative low molecular
weight heparin for Intracranial Neurosurgery.
General Surgery
LDUH or LMWH or Factor Xa Inhibitor (fondaparinux) com- General Surgery with a reason for Any of the following:
not administering pharmacologi-
cal prophylaxis
Intermittent pneumatic compression devices (IPC) Gynecologic Surgery
Intermittent pneumatic compression devices (IPC) LDUH or LMWH or Factor Xa Inhibitor (fondaparinux) com-bined with IPC or GCS Urologic Surgery
AMI/HF - ARBs (Table 2)
Intermittent pneumatic compression devices (IPC) LDUH or LMWH or Factor Xa Inhibitor (fondaparinux) com- Elective Total Hip Replacement
AMI/HF - Beta Blockers (Table 3)
SCIP - Diuretics (Table 10)
SCIP - Urinary Antiseptics (Table 11)
AMI - Fibrinolytics (Table 4)
Anisoylated Plasminogen-Strepto- rPA (RPA) AMI - Statins (Table 5)
Prophylactic ABX Regimen Selection for (Table 9)
HF
Discharge Instructions:
CABG, Other Cardiac or Vascular
Hysterectomy
(For pts discharged to home/home care/court or law enforcement)
Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or 1. Address all:
3. F/U Appt (no PRN)
5. HF Symptoms Worsening
Cefotetan, Cefoxitin, Ampicillin/Sulbactam, Clindamycin + Moxifl oxacin, Ciprofl oxacin, or or Ertapenem†
Important: All discharge medications should be noted clearly and accurately in the chart and listed in the Discharge Instructions. [Specifi c instructions apply. See data element.]
2. Give discharge instructions to patient/caregiver. (Documentation must verify)
Metronidazole + Amikacin, Gentamicin, or Evaluation of LVS Function:
Metronidazole + Moxifl oxacin, Ciprofl oxacin, or *Evaluate LVS function prior to arrival (no time limit), during stay, or defi nitively plan evaluation for after dis-
charge. Otherwise, **document a reason for Not evaluating.
* Includes documentation of LVSF. Note: Document clearly. Clindamycin + Moxifl oxacin, Ciprofl oxacin, or Hysterectomy (Principal) + Colon (Other)
Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or ‡ACEI/ARB at Discharge for LVSD: (Includes RAS/RAAS blockers/inhibitors)
Prescribe EITHER at discharge for pts with < 40% EF or moderate/severe LVSD; or document reason for No
‡Tables 1 & 2
Metronidazole + Amikacin, Gentamicin, or Documentation must clearly indicate the medication (listed by name) is being prescribed at discharge. Metronidazole + Moxifl oxacin, Ciprofl oxacin, or Clindamycin + Moxifl oxacin, Ciprofl oxacin, or Moderate or severe aortic stenosis [Counts for BOTH] Other explicitly documented reason by Phys/APN/PA/Pharmacist Phys/APN/PA/Pharmacist documentation that either an ACEI or an ARB was not given due to one of the following 5 conditions [Counts for BOTH]: Hip/Knee Arthroplasty
Metronidazole + Amikacin, Gentamicin, or Metronidazole + Moxifl oxacin, Ciprofl oxacin, or 5. Worsening renal function/renal disease/dysfunction A Conditional Hold with parameters (re: BP) counts as a reason IF there is documenta-
tion that the ACEI/ARB was held due to the specifi ed parameters.
Special Considerations
*For cardiac, orthopedic, and vascular surgery, if the patient is allergic to ß-lactam antibiotics, Vancomycin or
Special Note: Comfort Measures Only excludes cases from all measures.
**Vancomycin is acceptable with a Physician/APN/PA/Pharmacist documented justifi cation for its use. (See
data element Vancomycin)
† A single dose of Ertapenem is recommended for colon procedures.
Beginning with January 2012, the following measure was retired. Beginning with January 2012, the following measure was suspended. There are several reasons measures are retired: The suspended measures are those which CMS is considering retirement; however, due to public concern
1. Measure performance among hospitals is so high and unvarying that meaningful distinctions and im- over possible declination of adherence, data collection and submission may be continued and any data submit- provements in performance can no longer be made; ted will be publically reported on Hospital Compare.
2. Performance or improvement on a measure does not result in better patient outcomes; 3. A measure does not align with current clinical guidelines or practice; Because the measure is still considered “best practice” and an indicator of high quality, it will continue
4. There is the availability of a more broadly applicable measure for the topic; to be a part of this Core Measure Booklet.
5. There is the availability of a measure that is more proximal in time to desired patient outcomes for the 6. There is the availability of a measure that is more strongly associated with desired patient outcomes for Surgery Pts With Appropriate Hair Removal: [Suspended]
Either remove surgical site hair by clippers or depilatory OR do not perform hair removal. Clearly docu-
7. Collection or public reporting of a measure leads to negative unintended consequences other than ment actual hair removal or that hair removal was not done. The one retired measure, Adult Smoking Cessation Advice/Counseling, is considered “topped out,” indicating
that nationally, it has met and maintained a very high performance level, with little or no room for improvement.
Also, screening should apply to ALL patients, not just those with HF. No data will be collected or reported on
this HF measure.
Because this measure is still considered “best practice” and an indicator of high quality, it will con-
tinue to be a part of this Core Measures Help Booklet.
Adult Smoking Cessation Advice/Counseling: [Retired]
Give to pts with clear history of cigarette smoking anytime during the past year prior to arrival. Always inquire.
PNEUMONIA (CAP)
Urinary Catheter Removed: (Awareness of and monitoring need to continue urinary cath is crucial.)
Blood Cultures Performed:
Remove indwelling urethral catheter on *POD0 through POD2; or document reason on POD1 or POD2 for
1. Pts Transferred or Admitted w/in 24hrs of Hospital Arrival to ICU (due to PN or complications due to
continuing cath. *POD 0 = Anesthesia End Date. POD 2 ends at midnight.
Collect blood culture anytime from the day prior to arrival up to 24hrs after hospital arrival.
2. ED [Determined by clearly documented admit order]
If blood culture is done, collect blood culture prior to initial antibiotic.
2. Inserted after arrival but prior to discharge from *recovery/PACU (Insertion must be noted) Initial Antibiotic Selection: (See ‡Table 6, ‡‡Table 7 and ‡‡‡Table 8 for applicable medications)
3. Still in place upon discharge from **recovery/PACU (documented w/in 24hrs after anesthesia end time) (**Or
Administer, in accordance to ‡current antibiotic consensus recommendations, the initial antibiotic regi-
max of 6hrs after arrival to a recovery area other than PACU, i.e., ICU) men w/in 24hrs of arrival. Must clearly document to refl ect actual administration and 1. ABX Name; 2. Date
of Admin; 3. Time of Admin; 4. Route of ABX.
Allowance is given when documentation refl ects pt has *another source of infection (w/in the 1st 24hrs of ar-
Pt in ICU and receiving ‡diuretics (one dose counts)
rival), is ‡‡compromised, or has healthcare associated PN.
Phys/APN/PA reason documented for continuing cath postoperatively
Do Not Count: Physician orders alone (i.e., keep catheter); high risk of falls/any risk of falls
[* Francisella tularensis (tularemia) or Yersinia pestis (pneumonic plague) have been added. Please refer to
A medical staff-approved facility urinary catheter protocol. There must be physician documentation on the data element as specifi c inclusions/exclusions apply.]
POD0, POD1 or POD2 ordering/instructing the nursing staff to follow the formal protocol AND docu-
Note: The only B-lactam allergy regime is for Non-ICU, ‡‡‡pseudomonal risk patients.
mentation on POD1 or POD2 of a reason to continue catheterization in the protocol. The reason may be Special Note: Comfort Measures Only excludes cases from all measures.
The reason may be documented by a nurse. Beginning with January 2012, the following measures were retired. There are several reasons measures are retired: Excludes: Patients who had urological/gynecological/perineal procedures performed or patients who had a
1. Measure performance among hospitals is so high and unvarying that meaningful distinctions and im- urinary diversion or a urethral catheter or were being intermittently catheterized prior to hospital arrival provements in performance can no longer be made; ‡Table 10
2. Performance or improvement on a measure does not result in better patient outcomes; 3. A measure does not align with current clinical guidelines or practice; 4. There is the availability of a more broadly applicable measure for the topic; Perioperative Temperature Management: (Consistency in temp documentation will be helpful.)
5. There is the availability of a measure that is more proximal in time to desired patient outcomes for the Includes ALL patients – pediatric included—regardless of age. Excludes pts who did not have neuraxial/general anesthesia. 6. There is the availability of a measure that is more strongly associated with desired patient outcomes for Document *Active Warming intraoperatively to maintain normothermia AND/OR at least 1 body temp ≥
7. Collection or public reporting of a measure leads to negative unintended consequences other than 96.8F/36C 30 min prior to or 15 min after anesthesia end time; or Document **Intentional/Maintained Hypo-
thermia perioperatively. Documentation must refl ect use during the periop period.
The one retired measure, Adult Smoking Cessation Advice/Counseling, is considered “topped out,” indicating
[Intraop: From †Anesthesia Start to Anesthesia End Time]
that nationally, it has met and maintained a very high performance level, with little or no room for improvement. Also, screening should apply to ALL patients, not just those with PN. No data will be collected or reported on [Periop: Within 24hrs of incision through discharge from the PACU/recovery area Or max of 6hrs after arrival to a recovery area other than PACU, i.e., ICU)] Because this measure is still considered “best practice” and an indicator of high quality, it will con-
* Only modalities accepted: Forced air warming; Conductive warming, Resistive warming; Warm water
tinue to be a part of this Core Measures Help Booklet.
garments
** Any reference to cardiopulmonary bypass is considered automatic intentional hypothermia.
Adult Smoking Cessation Advice/Counseling: [Retired]
Give to pts with clear history of cigarette smoking anytime during the past year prior to arrival. Always inquire. † Anesthesia Start and Anesthesia End Times: Represent the beginning and ending of Anesthesia for the
principal procedure (or surgical episode if multiple procedures). It is recommended to view the Anesthesia Re-
Also retired were Antibiotic Received [Timing Measure] (due to possible unintended consequent of antibiotic
cord as the priority source; but other sources may be used. If no inclusion terms/phrases are noted, alternative overuse) and Infl uenza Vaccination and Pneumococcal Vaccination (due to the addition of a more broadly
terms/phrases that best represent the time (e.g., “procedure start” or “to PACU”) may be used, starting with the applicable measure topic—Global Immunization. These measures will no longer be a part of the Core
Measures Help Booklet.
PNEUMONIA Antibiotic Concensus Recommendations (Table 6)
Non-ICU Patients
For Non-ICU, Pseudomonal Risk Patients Only
Beta-Blocker Therapy Pts Receiving Beta-Blocker During Periop Period:
Give to pts (on daily BB therapy prior to arrival) during the periop period (the day prior to surgery through POD
B-lactam (IV or IM)
Antipneumococcal/Antipseudomonal B-lactam (IV)
2); or **document reason for Not giving beta-blocker periop.
[Ampicillin/Sulbactam, Cefotaxime, Ceftaroline, [Cefepime, Doripenem, Imipenem/Cilastatin, Meropenem, 1. Patients with a LOS postoperatively < 2 days: Looking for documentation of administration the day prior Macrolide (IV or PO)
Antipseudomonal Quinolone (IV or PO)
[Azithromycin, Clarithromycin, Erythromycin, [Ciprofl oxacin, Levofl oxacin **]
2. Patients with a LOS postoperative 2 or more days: Looking for documentation of administration the day prior to or day of surgery AND POD 1 or POD2 Reasons (Documented during periop period): Antipneumococcal/Antipseudomonal B-lactam (IV)
Antipneumococcal Quinolone Monotherapy
[Cefepime, Doripenem, Imipenem/Cilastatin, Meropenem, (IV or PO)
Concurrent use of intravenous inotropic medications during periop period [Gemifl oxacin, Levofl oxacin **, Moxifl oxacin]
Other reason by Phys/PA/APN/Pharmacist. Excludes NPO documentation.
Aminoglycoside (IV)
-A Conditional Hold with parameters (re: HR or BP) counts as a reason IF there is documentation that the beta-
+ either
blocker was held due to the specifi ed parameters.
B-lactam (IV or IM)
Antipneumococcal Quinolone (IV or PO)
[Ampicillin/Sulbactam, Cefotaxime, Ceftaroline, [Gemifl oxacin, Levofl oxacin **, Moxifl oxacin]
**A reason must be noted each day the BB is held or not administered.
or
Macrolide (IV or PO)
Note: If pt took BB prior to arrival, the time of the last dose must be documented, unless taken the day of Doxycycline (IV or PO)
[Azithromycin, Clarithromycin, Erythromycin, surgery, to determine if w/in 24hrs prior to incision. Excludes: Pregnant patients or patients with heart transplantation or ventricular assistant devices For Documented B-lactam Allergy Pts:
Aztreonam (IV or IM)
VTE Prophylaxis Ordered and Received:
Tigecycline (IV) Monotherapy
1. Order ‡VTE Recommended Prophylaxis (pharmacological and/or **mechanical) anytime from hospital
arrival to 24hrs after anesthesia end time AND Antipneumococcal Quinolone (IV or PO)
2. Administer
recommended prophylaxis w/in 24hrs prior to anesthesia start to 24hrs after anesthesia end [Gemifl oxacin, Levofl oxacin **, Moxifl oxacin]
time; or document reason for Not administering both mechanical and pharmacological prophylaxis.
+
Aminoglycoside (IV)
‡Table 12
** Any application of Mechanical VTE prophylaxis counts as ordered; no order or protocol required.
Excludes: Patients on continuous oral anticoagulation therapy prior to hospitalization Aztreonam (IV or IM)
[Aztreonam ***]
+
Levofl oxacin (IV or PO)
[Levofl oxacin **]
Pseudomonas Risk (One of the following):
1)Bronchiectasis, 2)“Pseudomonal Risk,” 3)Structural
Lung Disease AND documented hx of repeated antibiot-
ics or long term/chronic use of systemic corticosteroids
w/in the past 3 months
SCIP Principal Procedures applied: CABG, Other Cardiac, Hip/Knee Arthroplasty,
PNEUMONIA Antibiotic Concensus Recommendations (Table 6) continued
Colon, Hysterectomy, Vascular and *Other Major Surgery
ICU Patients
Antiipneumococcal/Antipseudomonal B-lactam (IV)
Prophylactic Antibiotic Received:
[Cefepime, Doripenem, Imipenem/Cilastatin, Merope- Initiate w/in 1hr [or 2hrs if rec’ving Vancomycin or a fl uoroquinolone] prior to surgical incision.
Macrolide (IV)
Must clearly document to refl ect actual administration and 1. ABX Name; 2. Date of Admin; 3. Time of
[Azithromycin, Erythromycin, Erythromycin Admin; 4. Route of ABX. Document suspected/diagnosed infections clearly. Aminoglycoside (IV)
+ either
B-lactam (IV)
+ either
*Prophylactic Antibiotic Selection:
[Ampicillin/Sulbactam, Cefotaxime, Ceftriaxone] Antipneumococcal Quinolone (IV)
Administer the ‡recommended prophylactic antibiotics for specifi c surgical procedures.
Must clearly document to refl ect actual administration and 1. ABX Name; 2. Date of Admin; 3. Time of
Antiipneumococcal/Antipseudomonal B-lactam (IV)
Admin; 4. Route of ABX. Document suspected/diagnosed infections clearly. [Cefepime, Doripenem, Imipenem/Cilastatin, Merope- Macrolide (IV)
‡Table 9
[Azithromycin, Erythromycin, Erythromycin *Prophylactic Antibiotic Discontinued:
If the patient has Francisella tularensis or Yersinia Discontinue prophylactic antibiotics [excluding ‡Urinary Antiseptics] w/in 24hrs (or 48hrs for CABG or Other
Antipneumococcal Quinolone (IV)
pestis risk as determined by Another Source of Cardiac Surgery) of anesthesia end time or document **Reasons to Extend Antibiotics.
[Levofl oxacin **, Moxifl oxacin]
Infection (see data element) the following is another + either
B-lactam (IV)
Treatment of Infection [currently diagnosed/suspected] [Ampicillin/Sulbactam, Cefotaxime, Ceftriaxone] Doxycycline (IV)
Documentation of a benign or malignant bone tumor of the same lower extremity on which the principal procedure of an original or revised arthroplasty was performed Antiipneumococcal/Antipseudomonal B-lactam (IV)
+ either
Use of Erythromycin for increasing gastric motility [Cefepime, Doripenem, Imipenem/Cilastatin, Merope- B-lactam IV
[Ampicillin/Sulbactam, Cefotaxime, Ceftriaxone] Treatment of syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH) of Antiipneumococcal/Antipseudomonal B-lactam (IV)
[Cefepime, Doripenem, Imipenem/Cilastatin, (**Must be Phys/APN/PA documentation. Please refer to data element for specifi c
Antipseudomonal Quinolone (IV)
documentation time frames, etc.)
[Ciprofl oxacin, Levofl oxacin **]
‡Table 11
+ either
B-lactam (IV)
*Antibiotic (SCIP-Inf) Measures exclude Other Major Surgery
[Ampicillin/Sulbactam, Cefotaxime, Ceftriaxone] or
Antipneumococcal/Antipseudomonal B-lactam
Cardiac Surgery Pts with Controlled 6AM Postop Blood Glucose:
Control pt’s 6AM blood glucose to ≤200 mg/dL on Postop Day 1 (POD1) AND Postop Day 2 (POD2).
[Cefepime, Doripenem, Imipenem/Cilastatin, Merope-nem, Piperacillin/Tazobactam] Suggestion: Maintain and document blood glucose levels throughout the entire postop period. Excludes: Burn patients, transplant patients and patients with preop infections ** Levofl oxacin should be used in 750mg dosage when used in the management of patients with pneumonia.
*** For patients with renal insuffi ciency.
PN - Immunosuppresives (Table 7)
PN - Systemic Corticosteroids (Table 8)
Hydrocortone Phosphate Repository Corticotropin Aristospan Intra-articular Dexamethasone Acetate Liquid Pred Betamethasone Sodium Phosphate with Lidocaine M-Prednisol Hydrocortisone Cypionate Prednisolone Acetate Hydrocortisone Retention Prednisolone Sodium PN - Immunosuppresives (Table 7) cont.
PN - Immunosuppresives (Table 7) cont.
PN - Immunosuppresives (Table 7) cont.
PN - Immunosuppresives (Table 7) cont.
Iodine I 131 Tositumomab Mechlorethamine HCL

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