Measure Information Form

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1 Release Notes: Measure Information Form Version 2.4 **NQF-NORS VOLUNTARY CONSNSUS STANARS FOR HOSPITAL CAR** Measure Information Form Measure Set: Surgical Care Improvement Project (SCIP) Set Measure I #: SCIP- Set Measure I # 2a 2b* 2c* 2d* 2e* 2f* 2g* 2h* *The Joint Commission ONLY Performance Measure Prophylactic Selection for Surgical Patients - Overall Rate Prophylactic Selection for Surgical Patients - CAG Prophylactic Selection for Surgical Patients - Other Cardiac Surgery Prophylactic Selection for Surgical Patients - Hip Arthroplasty Prophylactic Selection for Surgical Patients - Knee Arthroplasty Prophylactic Selection for Surgical Patients - Colon Surgery Prophylactic Selection for Surgical Patients - Hysterectomy Prophylactic Selection for Surgical Patients - Vascular Surgery Performance Measure : Prophylactic Selection for Surgical Patients. escription: Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. First or second-generation cephalosporins satisfy these criteria for most operations, although anaerobic coverage is needed for colon surgery. Vancomycin is not recommended for routine use because of the potential for development of antibiotic resistance, but is acceptable if a patient is allergic to beta-lactams, as are fluoroquinolones and clindamycin in selected situations. Type of Measure: Process Improvement Noted As: An increase in the rate. Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-1 ischarges (2Q08) through (3Q08)

2 Numerator Statement: Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure. Included populations: Not Applicable xcluded Populations: None ata lements: Administration Route Allergy Oral s Vancomycin The antibiotic regimens described in the table which follows later in this section reflect the combined, published recommendations of the American Society of Health-System Pharmacists, the Medical Letter, the Infectious iseases Society of America, the Sanford Guide to Antimicrobial Therapy 2001, and the Surgical Infection Society. enominator Statement: All selected surgical patients with no evidence of prior infection. Included Populations: An IC-9-CM of selected surgeries (refer to Appendix A, Table 5.10 for IC-9-CM codes). AN An IC-9-CM of selected surgeries (refer to Appendix A, Table for IC-9-CM codes). xcluded Populations: Patients who had a principal diagnosis suggestive of preoperative infectious diseases (refer to Appendix A, Table 5.09 for IC-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 did not receive any antibiotics before or during surgery, or within 24 hours after surgery end time (i.e., patient did not receive prophylactic antibiotics). Patients who did not receive any antibiotics during this hospitalization. Patients less than 18 years of age. Patients with physician/advanced practice nurse/physician assistant (physician/apn/pa) documented infection prior to surgical procedure of interest. Patients whose IC-9-CM principal procedure occurred prior to the date of admission. Patients whose IC-9-CM principal procedure was performed entirely by laparoscope. Patients involved in clinical trials. Patients who expired perioperatively. Patients who had a joint revision. Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-2 ischarges (2Q08) through (3Q08)

3 Patients who have a length of Stay >120 days ata lements: Admission ate Administration ate Administration Time Received irthdate Clinical Trial ischarge ate IC-9-CM iagnosis Code IC-9-CM Infection Prior to Anesthesia Joint Revision Laparoscope Perioperative eath Surgery nd ate Surgery nd Time Surgery Start ate Surgical Incision Time Risk Adjustment: No ata Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. ata Accuracy: Abstracted antibiotics are those administered from the time of arrival through the first 48 hours (72 hours for CAG or Other Cardiac Surgery) after the surgery end time. Refer to Appendix C, Table 2.1, which contains a complete listing of antibiotics. Measure Analysis Suggestions: Consideration may be given to relating this measure to SCIP- Inf-1 and 3 in order to evaluate which aspects of antibiotic prophylaxis would most benefit from an improvement effort. The process owners for selection of appropriate antibiotics could include physicians/apns/pas and hospital committees (i.e., QA, Infection Control, Pharmacy and Therapeutics, Surgical Section Subcommittees, etc.) any of which may choose to address this physician/apn/pa practice issue as part of a larger surgical infection prevention initiative. Sampling: Yes, for additional information see the Population and Sampling Specifications Section. ata Reported As: Overall aggregate rate for all surgeries and stratified rates by data element IC-9-CM, generated from count data reported as a proportion. Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-3 ischarges (2Q08) through (3Q08)

4 Selected References: ratzler W, Houck PM, for the Surgical Infection Prevention Guidelines Writers Group. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. CI. 2004:38(15 July): Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, Infect Control Hosp pidemiol. 1999;20: American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56: No author listed. Treatment Guidelines from The Medical Letter. Antimicrobial Prophylaxis for Surgery. Med Lett rugs Ther 2006; 52: ellinger P, Gross PA, arrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect is. 1994;18: Gilbert N, Moellering RC Jr., Sande MA, eds. The Sanford Guide to Antimicrobial Therapy. 31 st ed. Hyde Park, VT: Antimicrobial Therapy, Inc; 2001.pp Itani KMF, Wilson S, Awad SS, Jensen H, Finn TS, Abramson MA. rtapenem versus cefotetan prophylaxis in elective colorectal surgery. N ngl J Med ec 21; 355 (25): Page CP, ohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Arch Surg. 1993;128: American College of Obstetricians and Gynecologists (ACOG) Committee on Practice ulletins. ACOG Practice ulletin No. 74 prophylaxis for gynecologic procedures. Obstet Gynecol July 2006; 108(1): Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-4 ischarges (2Q08) through (3Q08)

5 Prophylactic Regimen Selection for Surgery Surgical Procedure CAG, Other Cardiac or Vascular Hip/Knee Arthroplasty Colon Hysterectomy Special Considerations Approved s Cefazolin, Cefuroxime,Table 3.1 or Vancomycin** Table 3.8 If β-lactam allergy: Vancomycin* Table 3.8 or Clindamycin* Table 3.9 Cefazolin or Cefuroxime Table 3.2 or Vancomycin** Table 3.8 If β-lactam allergy: Vancomycin* Table 3.8 or Clindamycin* Table 3.9 Cefotetan, Cefoxitin, Ampicillin/Sulbactam Table 3.5, or rtapenem Table 3.6b OR Cefazolin or Cefuroxime Table Metronidazole Table 3.6a If β-lactam allergy: Clindamycin Table Aminoglycoside Table 2.11, or Clindamycin Table Quinolone Table 3.12, or Clindamycin Table Aztreonam Table 2.7 OR Metronidazole Table 3.6a with Aminoglycoside Table 2.11, or Metronidazole Table 3.6a + Quinolone Table 3.12 Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or Ampicillin/Sulbactam Table 3.7 If β-lactam allergy: Clindamycin Table 3.9 OR Metronidazole Table 3.6a *For cardiac, orthopedic, and vascular surgery, if the patient is allergic to β-lactam antibiotics, Vancomycin or Clindamycin are acceptable substitutes. **Vancomycin is acceptable with a physician/apn/pa documented justification for its use (see data element Vancomycin) A single dose of ertapenem is recommended for colon procedures. Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-5 ischarges (2Q08) through (3Q08)

6 SCIP-: Prophylactic Selection for Surgical Patients Numerator: Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure. enominator: All selected surgical patients with no evidence of prior infection. START Variable Key: ays I Timing I ays II Timing II Surgery ays Abxday Flag Run cases that are included in the SCIP Initial Patient Population and pass the edits defined in the Front-nd Algorithm through this measure. IC-9-CM Procedure Code 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 Not 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 Stratification Table: Set# Stratified y * (Allowable Value) SCIP-INF2a Overall Rate ** SCIP-INF2b CAG Table 5.01 SCIP-INF2c Other Cardiac Surgery Table 5.02 SCIP-INF2d Hip Arthroplasty Table 5.04 SCIP-INF2e Knee Arthroplasty Table 5.05 SCIP-INF2f Colon Surgery Table 5.03 SCIP-INF2g Hysterectomy Table 5.06 Or 5.07 SCIP-INF2h Vascular Surgery Table 5.08 * This refers to the data element 'IC-9-CM. ach case will be stratified according to the principal procedure code, after the Category Assignments are completed and the overall rate is calculated. ** No allowable value exists for the overall rate. It includes all procedures on Tables 5.01 to IC-9-CM iagnosis Code On Table 5.09 Not on Table 5.09 Laparoscope =1,3 =2 Clinical Trial = Y = N H Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-6 ischarges (2Q08) through (3Q08)

7 H Surgery Start ate =UT Non-UT Value Surgery ays (in days) = Surgery Start ate Admission ate Surgery ays < 0 0 Infection Prior to = Y Anesthesia = N IC-9-CM On Table 5.04 or 5.05 Joint Revision =Y Not on Table 5.04 or 5.05 = N Perioperative eath =Y = N Received = 1, 2 IC-9-CM Procedure Code Not on Table 5.03 = 3, 4 On Table 5.03 Oral s = N Received = 4 =Y = 3 Received = 1 =2 I Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-7 ischarges (2Q08) through (3Q08)

8 I Note: The front-end edits reject cases containing invalid data and/ or an incomplete Grid. A complete Grid requires all data elements in the row to contain either a valid value and/or UT. Grid Not Populated Note: Proceed only with antibiotic doses on Table 2.1 in Appendix C. On Table 2.1 for at least one antibiotic Administration Route =3,10 for all antibiotic doses =1,2 for any antibiotic dose Proceed only with antibiotic doses on Table 2.1 that are administered via routes 1 or 2. Administration ate =UT for all antibiotic doses Non-UT date for at least one antibiotic dose ays I = Surgery Start ate - Administration ate (in days) Note: Proceed only with antibiotic doses that have an associated non-ut date. ays I > 1 for at least one antibiotic dose 1 for all antibiotic doses ays I 0 for ALL antibiotic doses J =1 for ANY antibiotic dose Surgical Incision Time =UT Non-UT Value Administration Time = UT for all antibiotic doses OR =UT for ANY antibiotic doses with ays I = 1 Non-UT time for at least one antibiotic dose Timing I = Surgery Start ate and Surgical Incision Time - Administration ate and Administration Time (in minutes). Calculate Timing I for all antibiotic doses with non-ut date and time. Proceed with antibiotic doses that have Timing I calculated, or ays I 0. Timing I > 1440 minutes for any antibiotic dose. Proceed with antibiotic doses that have Timing I calculated, or ays I 0. IC-9-CM Procedure Code Not on Table minutes for all antibiotic doses with non-ut date and time. Proceed with antibiotic doses that have Timing I calculated, or ays I 0. On Table 5.03 Oral s = N J =Y Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-8 ischarges (2Q08) through (3Q08)

9 J Surgery nd ate =UT Non-UT Value ays II = Administration ate - Surgery nd ate (in days) ays II 0 for all doses of all s K > 0 for at least one dose of any antibiotic Initialize Abxday flag = No for each antibiotic doses. Set Abxday flag = Yes for each antibiotic dose where ays II<= 0. Surgery nd Time =UT Abxday flag =No for All doses Non-UT Value =Yes for ANY dose. Proceed with Abxday flag=yes. Administration Time =UT for all antibiotic doses Abxday flag =No for ALL oses Non-UT time for at least one antibiotic dose. Proceed with both UT and Non-UT time. =Yes for ANY dose. Proceed with Abxday flag=yes. Timing II = Administration ate and Administration Time - Surgery nd ate and Surgery nd Time (in minutes). Calculate Timing II for all antibiotic doses with non-ut date and time. Proceed with antibiotic doses that have Timing II calculated, or Abxday flag = Yes. Timing II > 1440 minutes for all doses of all s with non-ut date and time. Proceed with antibiotic doses that have Timing II calculated, or Abxday flag = Yes. Abxday flag =No for ALL oses <= 1440 minutes for at least one dose of ANY. Proceed with antibiotic doses that have Timing II calculated, or Abxday flag = Yes. =Yes for ANY dose. Proceed with Abxday flag=yes. For each case, proceed ONLY with those antibiotic doses that satisfy at least one of the following conditions: Timing II <= Abxday flag = Y K Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-9 ischarges (2Q08) through (3Q08)

10 K Administration Route = 1 for all doses of all s = 2 for any dose of any Note: For each case include only those antibiotics with routes IV for further processing IC-9-CM On Table 5.03 L On Table 5.01 or 5.02 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 IC-9-CM On Table 5.06 or 5.07 On Table 3.7 Not on Table 3.7 On Table 5.01 or 5.02 or 5.04 or 5.05 or 5.08 M IC-9-CM On Tables 5.01, 5.02, 5.08 On Table 3.1 Not on Table 3.1 On Table 5.04 or 5.05 M On Table 3.2 Not on Table 3.2 M Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-10 ischarges (2Q08) through (3Q08)

11 L On Table 3.6b Not on Table 3.6b On Table 3.5 Not on Table 3.5 On Table 3.2 On Table 3.6a Not on Table 3.2 M Not on Table 3.6a Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-11 ischarges (2Q08) through (3Q08)

12 M None on Table 3.8 and None on Table 3.9 IC-9-CM On Tables 5.01, 5.02, 5.04, 5.05, 5.08 At least one on Table 3.8 or 3.9 Allergy =Y =N On Tables 5.03, 5.06, 5.07 None on Table 3.8 At least one on Table 3.8 Allergy = N Any = 9 And None = 1,2,3,4,5,6, 7, 8, 10, 11 Vancomycin Case Will e Rejected = Y Any =1,2,3,4,5,6,7,8, 10, 11 and none = 9 For Overall Rate (a) IC-9-CM Procedure Code On Table 5.03 On Table 5.06, 5.07 None on Tables 3.9 or 3.6a At least one on Tables 3.9 Or 3.6a At least one on Table 3.9 At least one on Tables 2.11 or 3.12 or 2.7 None on Table 3.9 None on Tables 2.11 or 3.12 or 2.7 At least one on Table 3.6a At least one on Tables 2.11 or 3.12 In Numerator Population For Overall Rate (a) For Overall Rate (a) Not in Measure Population None on Table 3.6a Measure Population In None on Tables 2.11 or 3.12 For Overall Rate (a) N STOP here for CMS. CONTINU to N for The Joint Commission. Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-12 ischarges (2Q08) through (3Q08)

13 For all Stratified Measures (b-h) N Not In Measure Population Note: Initialize the Measure Category Assignment for each strata measure (b-g) = ''. o not change the Measure Category Assignment that was already calculated for the overall rate (SCIP-a). The rest of the algorithm will reset the appropriate Measure Category Assignment to be equal to the overall rate's (SCIP-a) Measure Category Assignment Overall Rate Category Assignment = or Set the Measure Category Assignment for the strata measures (SCIP-b through SCIP-h) = '' Z = or For Stratified Measure SCIP -b IC-9-CM On Table 5.01 Set the Measure Category Assignment for measure SCIP-b = the Measure Category Assignment 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 For Stratified Measure SCIP -c IC-9-CM On Table 5.02 Set the Measure Category Assignment for SCIP-c = the Measure Category Assignment for measure SCIP-a Z On Table 5.03 or 5.04 or 5.05 or 5.06 or 5.07 or 5.08 For Stratified Measure SCIP -d IC-9-CM On Table 5.04 Set the Measure Category Assignment for measure SCIP-d = the Measure Category Assignment for measure SCIP-a Z On Table 5.03 or 5.05 or 5.06 or 5.07 or 5.08 O Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-13 ischarges (2Q08) through (3Q08)

14 O For Stratified Measure SCIP-e IC-9-CM On Table 5.05 Set the Measure Category Assignment for measure SCIP-e = the Measure Category Assignment for measure SCIP-a On Table 5.03 or 5.06 or 5.07 or 5.08 For Stratified Measure SCIP-f IC-9-CM On Table 5.03 Set the Measure Category Assignment for measure SCIP-f = the Measure Category Assignment for measure SCIP-a On Table 5.06 or 5.07 or 5.08 For Stratified Measure SCIP-g IC-9-CM On Table 5.06 or 5.07 Set the Measure Category Assignment for measure SCIP-g = the Measure Category Assignment for measure SCIP-a On Table 5.08 For Stratified Measure SCIP-h Set the Measure Category Assignment for measure SCIP-h = the Measure Category Assignment for measure SCIP-a Z Stop Specifications Manual for National Hospital Quality Measures SCIP-Inf 2-14 ischarges (2Q08) through (3Q08)