Measure Information Form

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1 Release Notes: Measure Information Form Version 2.0 **NQF-NDORSD VOUNTRY CONSNSUS STNDRDS FOR HOSPIT CR** Measure Information Form Measure Set: Surgical Care Improvement Project (SCIP) Set Measure ID #: SCIP- Set Measure ID # 3a 3b 3c 3d 3e 3f 3g 3h Performance Measure Name Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Overall Rate Prophylactic ntibiotics Discontinued Within 48 Hours fter Surgery nd Time - CG Prophylactic ntibiotics Discontinued Within 48 Hours fter Surgery nd Time Other Cardiac Surgery Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Hip rthroplasty Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Knee rthroplasty Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Colon Surgery Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Hysterectomy Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time - Vascular Surgery Performance Measure Name: Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time* Description: Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. *The Society of Thoracic Surgeons (STS) Practice Guideline for ntibiotic Prophylaxis in Cardiac Surgery (2005) has been published. ecause of this new guideline, CMS and JCHO have revised SCIP- relevant to cardiac surgery (CG and Other Cardiac Surgery) only. The published STS guideline indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery. Rationale: goal of prophylaxis with antibiotics is to provide benefit to the patient with as little risk as possible. It is important to maintain therapeutic serum and tissue levels throughout the operation. Intraoperative re-dosing may be needed for long operations. However, administration Specifications Manual for National SCIP-Inf 3-1

2 of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged administration does increase the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens. Type of Measure: Process Improvement Noted s: n increase in the rate Numerator Statement: Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours for CG or Other Cardiac Surgery) Included Populations: Not pplicable xcluded Populations: None Data lements: ntibiotic dministration Date ntibiotic dministration Time Surgery nd Date Surgery nd Time Denominator Statement: ll selected surgical patients with no evidence of prior infection Included Populations: n ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes of selected surgeries (refer to ppendix, Table 5.10 for ICD-9-CM codes) ND n ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes of selected surgeries (refer to ppendix, Table for ICD-9-CM codes) xcluded Populations: Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases (refer to ppendix, Table 5.09 for ICD-9-CM codes) Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics) Patients who were receiving antibiotics more than 24 hours prior to surgery (except colon surgery patients taking oral prophylactic antibiotics) Patients who were diagnosed with and treated for infections within two days (3 days for CG and Other Cardiac Surgery) after Surgery nd Date Patients who did not receive any antibiotics during this hospitalization Patients less than 18 years of age Patients with physician documented infection prior to surgical procedure of interest Patients who had other procedures requiring general or spinal anesthesia that occurred within 3 days (4 days for CG and Other Cardiac Surgery) prior to or after the procedure of interest (during separate surgical episodes) during this hospital stay Patients whose procedure of interest occurred prior to date of admission Specifications Manual for National SCIP-Inf 3-2

3 Data lements: dmission Date dmission Diagnosis of ntibiotic Name ntibiotics During Stay ntibiotics Prior to rrival irthdate Date of arly ntibiotics ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code Prior to nesthesia Oral ntibiotics Other Surgeries Postoperative s Surgery Performed During Stay Surgery Start Date Surgical Incision Time Risk djustment: No Data Collection pproach: Retrospective data sources for required data elements include administrative data and medical records. Data ccuracy: bstracted antibiotics are those administered from the time of arrival through the first 48 hours (72 hours for CG or Other Cardiac Surgery) after the surgery end time. Refer to ppendix C, Table 2.1, which contains a complete listing of antibiotics. Measure nalysis Suggestions: Consideration may be given to relating this measure to SCIP- Inf-1 and 2 in order to evaluate to which aspects of antibiotic prophylaxis would most benefit from an improvement effort. The process-owners of the timing of discontinuation of antibiotics subsequent to surgery include physicians and their assistants, the post-surgical recovery team, as well as the postoperative nursing unit. y including the appropriate groups involved in the postoperative care process, one can more clearly ascertain where in the process the team may need to focus for improvement. Sampling: Yes, for additional information see the Sampling Section. Data Reported s: Overall aggregate rate for all surgeries and stratified rates by data element, generated from count data reported as a proportion Specifications Manual for National SCIP-Inf 3-3

4 Selected References: ratzler DW, Houck PM, for the Surgical Prevention Guidelines Writers Group. ntimicrobial prophylaxis for surgery: n advisory statement from the National Surgical Prevention Project. CID. 2004:38(15 July): Crabtree TD, Pelletier SJ, Gleason TG, et al. Clinical characteristics and antibiotic utilization in surgical patients with Clostridium difficile-associated diarrhea. m Surg. 1999;65: Mangram J, Horan TC, Pearson M, et al. Guidelines for prevention of surgical site infection, Infect Control Hosp pidemiol. 1999;20: McDonald M, Grabsch, Marshall C, et al. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systemic review. ust N Z J Surg. 1988;68: Scher KS. Studies on the duration of antibiotic administration for surgical prophylaxis. m Surg. 1997;63: Specifications Manual for National SCIP-Inf 3-4

5 SCIP-: Prophylactic ntibiotics Discontinued Within 24 Hours fter Surgery nd Time Numerator: Number of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (48 hours if CG or Other Cardiac Surgery ). Denominator: ll selected surgical patients with no evidence of prior infection. ll Start ICD-9-CM Principal or Other Procedure Code t least one on Table 5.10 dmission Date irthdate Patient ge (in years) = dmission Date - irthdate Note: If two procedures of interest are performed during the same operative time frame, choose the surgery listed as the principal procedure as the surgical procedure of interest for the specific episode of care. ll Missing or None on Table 5.10 Variable Key: Patient ge ntibiotic Days I ntibiotic Days II ntibiotic Timing I ntibiotic Timing II Post Operative Days Surgery Days Surgery Match Stratification Table: Set# Stratified y * Procedure Of (llowable Value) SCIP-Inf3a Overall Rate ** SCIP-Inf3b CG Table 5.01 SCIP-Inf3c Other Cardiac Surgery Table 5.02 SCIP-Inf3d Hip rthroplasty Table 5.04 SCIP-Inf3e Knee rthroplasty Table 5.05 SCIP-Inf3f Colon Surgery Table 5.03 SCIP-Inf3g Hysterectomy Table 5.06 Or 5.07 SCIP-Inf3h Vascular Surgery Table 5.08 * This refers to the data element '. ach case will be stratified according to the procedure code for that, after the Category ssignments are completed and overall rate is calculated. ** No allowable value exists for the overall rate. It Includes all procedures on Tables 5.01 to age < 0 days (negative value) Patient ge age > or = 0 days and < 18 years age >= 18 years Initial population common to all SCIP measures ICD-9-CM Principal or Other Procedure Code None on Table 5.01 or 5.02 or 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 t least one on Table 5.01 or 5.02 or 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 or None on Tables On Table 5.01 or 5.02 or 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 Surgery Match = Set Surgery Match = Yes if equals the ICD-9-CM Principal or Other Procedure Code as determined to be on any of Tables 5.01 to 5.08 from the previous steps. lse set Surgery Match to No o Surgery Match =Yes H Specifications Manual for National SCIP-Inf 3-5

6 H ICD-9-CM Principal Diagnosis Code On Table 5.09 Not on Table 5.09 Surgery Start Date Surgery Days (in days) = Surgery Start Date dmission Date Surgery Days < 0 0 dmission Diagnosis of = Y Surgery Performed During Stay = Y Prior to nesthesia = Y ntibiotics Prior To rrival = Y Procedure Of Not on Table 5.03 On Table 5.03 Missing / Oral ntibiotics =Y ntibiotics During Stay Missing / ntibiotics During Stay = Y =Y arly ntibiotics =Y Procedure Of Not on Table 5.03 I On Table 5.03 Specifications Manual for National SCIP-Inf 3-6

7 I Missing/ for all antibiotic doses ntibiotic Name Note: Only proceed with antibiotic doses with valid name. Check against the list of antibiotics on Table 2.1 in ppendix C. On Table 2.1 for all antibiotic doses ntibiotic dministration Date Note: Proceed only with antibiotic doses that have valid dates. for at least one dose of an antibiotic ntibiotic Days I = Surgery Start Date - ntibiotic dministration Date (in days) ntibiotic Days I > 1 for any antibiotic dose 1 for all antibiotic doses ntibiotic Days I < 0 for all antibiotic doses J 0 for any antibiotic dose Missing/ Surgical Incision Time Missing / for all antibiotic doses ntibiotic dministration Time Note: Proceed only with antibiotic doses that have valid times. for at least one dose of antibiotic ntibiotic Timing I = Surgery Start Date and Surgical Incision Time - ntibiotic dministration Date and Time (in minutes) ntibiotic Timing I > 1440 minutes for any antibiotic dose Procedure Of Not on Table minutes for all antibiotic doses On Table 5.03 J Missing/ Oral ntibiotics =Y J Specifications Manual for National SCIP-Inf 3-7

8 J Missing/ Other Surgeries = Y For Overall Rate (a) Surgery nd Date Missing or Measure Population Data Postoperative = Y Date Of s Post Operative Days = Date of - Surgery nd Date (in days) Procedure Of On Table 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 On Table 5.01 or 5.02 > 3 days Post Operative Days 3 days > 2 days Post Operative Days 2 days Not In Measure Population ntibiotic Days II = ntibiotic dministration Date - Surgery nd Date (in days) For Overall Rate (a) ntibiotic Days II 0 for all antibiotic doses > 0 for at least one antibiotic dose On Table 5.01 or 5.02 ntibiotic Days II < 2 days for all antibiotic doses On Table 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or days for at least one antibiotic dose K Specifications Manual for National SCIP-Inf 3-8

9 K Surgery nd Time C Missing or Numerator Data for all antibiotic doses ntibiotic dministration Time for at least one antibiotic dose Proceed only with antibiotic doses that have a valid time. ntibiotic Timing II = ntibiotic dministration Date and Time - Surgery nd Date and Surgery nd Time (in minutes) D >2880 minutes for at least one antibiotic dose ntibiotic Timing II On Table 5.01 or 5.02 Procedure Of On Table 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 ntibiotic Timing II 1440 minutes for all antibiotic doses 2880 minutes for all antibiotic doses > 1440 minutes for at least one antibiotic dose D D For Overall Rate (SCIP-a) In Numerator Population For Overall Rate (SCIP-a) Measure Population DIn STOP FOR CMS. CONTINU FOR JCHO Specifications Manual for National SCIP-Inf 3-9

10 For all Stratified Measures (b-h) Not In Measure Population Note: Initialize the Measure Category ssignment for each strata measure (b-g) = ''. Do not change the Measure Category ssignment that was already calculated for the overall rate (SCIP-a). The rest of the algorithm will reset the appropriate Measure Category ssignment to be equal to the overall rate's (SCIP-a) Measure Category ssignment Overall Rate Category ssignment = or or C Set the Measure Category ssignment for the strata measures (SCIP-b through SCIP-h) = '' Z = D or SCIP-b On Table 5.01 Set the Measure Category ssignment for measure SCIP-b = the Measure Category ssignment for measure SCIP-a Z On Table 5.02 or 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 SCIP -c On Table 5.02 Set the Measure Category ssignment for SCIP-c = the Measure Category ssignment for measure SCIP-a Z On Table 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 SCIP -d On Table 5.04 Set the Measure Category ssignment for measure SCIP-d = the Measure Category ssignment for measure SCIP- a Z On Table 5.03 or 5.05 or 5.06 or 5.07 or 5.08 M Specifications Manual for National SCIP-Inf 3-10

11 M SCIP-e On Table 5.05 Set the Measure Category ssignment for measure SCIP-e = the Measure Category ssignment for measure SCIP-a On Table 5.03 or 5.06 or 5.07 or 5.08 SCIP-f On Table 5.03 Set the Measure Category ssignment for measure SCIP-f = the Measure Category ssignment for measure SCIP-a On Table 5.06 or 5.07 or 5.08 SCIP-g On Table 5.06 or 5.07 Set the Measure Category ssignment for measure SCIP-g = the Measure Category ssignment for measure SCIP-a On Table 5.08 SCIP-h Set the Measure Category ssignment for measure SCIP-h = the Measure Category ssignment for measure SCIP-a Z Stop Specifications Manual for National SCIP-Inf 3-11

Measure Information Form

Release Notes: Measure Information Form Version 2.0 **NQF-NDORSD VOLUNTRY CONSNSUS STNDRDS FOR HOSPITL CR** Measure Information Form Measure Set: Surgical Care Improvement Project (SCIP) Set Measure ID