NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE. Measure Information Form

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1 Last Updated: Version 3.2a NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE Measure Set: Pneumonia (PN) Performance Measure Identifier: Measure Information Form Organization Set Measure ID# Measure Population CMS ICU & Non - ICU Patients The Joint Commission a ICU Patients The Joint Commission b Non - ICU Patients Note: CMS data is transmitted as patient level data while the Joint Commission s data is transmitted as aggregate level data. Therefore, in order for The Joint Commission to distinguish between ICU and non-icu patients, two separate measures are required for data transmission. Performance Measure Name: () Initial Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients (a) Initial Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients Intensive Care Unit (ICU) Patients (b) Initial Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients Non ICU Patients Description: () Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines (a) Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines (b) Immunocompetent non-intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines Rationale: The current North American antibiotic guidelines for Community-Acquired Pneumonia in immunocompetent patients are from the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS). All four reflect that Streptococcus pneumoniae is the most common cause of CAP, that treatment that covers atypical pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with, 6ab-1

2 improved survival, and that the prevalence of antibiotic resistant S. pneumoniae is increasing. The CMS convened a conference of guideline authors, including Julie Gerberding, MD (CDC), John Bartlett, MD (IDSA), Ronald Grossman, MD (CIDS/CTS), and Michael Niederman, MD (ATS), to reach consensus on the antibiotic regimens that could be considered consistent with all four organizations guidelines. These regimens are reflected in this measure, and in the Pneumonia Consensus Recommendation located directly behind the measure information form. Type of Measure: Process Improvement Noted As: An increase in the rate/score/number of occurrences Numerator Statement: Pneumonia patients who received an initial antibiotic regimen (as specified under the Set Measure Identifier and description above) consistent with current guidelines during the first 24 hours of their hospitalization Included populations Excluded Populations Data Elements a b Pneumonia patients ICU pneumonia Non-ICU who received antibiotics patients who received pneumonia patients consistent with current antibiotics consistent who received guidelines with current guidelines antibiotics consistent with current guidelines None None None Date Route Time Allergy Name Arrival Date Arrival Time Pseudomonas Risk Risk Factors for Drug- Resistant Pneumococcus Date Route Time Allergy Name Arrival Date Arrival Time Date Route Time Allergy Name Arrival Date Arrival Time Pseudomonas Risk Risk Factors for Drug-Resistant Pneumococcus Denominator Statement: Pneumonia patients (as specified under the Set Measure Identifier and description above) 18 years of age and older, 6ab-2

3 Included Populations: Discharges with: An ICD-9-CM Principal Diagnosis Code of pneumonia as defined in Appendix A, Table 3.1 OR ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as defined in Appendix A, Tables 3.2, or 3.3 AND An ICD-9-CM Other Diagnosis Code of pneumonia (Appendix A, Table 3.1) Excluded Populations: Patients less than 18 years of age Patients who have a Length of Stay greater than 120 days Patients with Cystic Fibrosis (Appendix A, Table 3.4) Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Patients with Comfort Measures Only documented on day of or day after arrival Patients enrolled in clinical trials Patients received as a transfer from the emergency/observation department of another hospital Patients received as a transfer from an inpatient or outpatient department of another hospital Patients received as a transfer from an ambulatory surgery center Patients who have no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression PN patients not in the ICU (a only) PN patients in ICU (b only) Patients with Healthcare Associated PN as defined in the Data Dictionary Patients who are Compromised as defined in the Data Dictionary Patients transferred/admitted to the ICU within 24 hours after arrival to this hospital, with a beta-lactam allergy Patients who have duration of stay less than or equal to one day Pneumonia patients with Another Source of Infection who did not receive an antibiotic regimen recommended for pneumonia, but did receive antibiotics within the first 24 hours of hospitalization Data Elements: Admission Date Another Source of Infection Date Time Name Received Birthdate, 6ab-3

4 Chest X-Ray Clinical Trial Comfort Measures Only Compromised Discharge Date Healthcare Associated PN ICD-9-CM Other Diagnosis Codes ICD-9-CM Principal Diagnosis Code ICU Admission or Transfer Pneumonia Diagnosis: ED/Direct Admit Risk Factors for Drug-Resistant Pneumococcus ( and b only) Transfer From Another Hospital or ASC Risk Adjustment: No Data Collection Approach: Retrospective, data sources for required data elements include administrative data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunity for improvement at the point of care/service. However, complete documentation includes the final ICD-9-CM diagnosis and procedure codes, which require retrospective data entry. Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. Measure Analysis Suggestions: The time of antibiotic administration is critical to this measure. For quality improvement purposes, the ORYX Vendor may want to create reports to identify patients who received their antibiotic consistent with guidelines but greater than 24 hours from the time of arrival, and patients who did not receive an antibiotic consistent with guidelines. This will allow healthcare organizations to direct education effort in the appropriate direction (e.g., appropriate antibiotic selection or timing of administration). Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. Data Reported As: Aggregate rate generated from count data reported as a proportion Selected References: Butler JC, Hofmann J, Cetron MS, et al. The continued emergence of drugresistant Streptococcus pneumonia in the United States: an update from the Centers for Disease Control and Prevention s Pneumococcal Sentinel Surveillance System. J Infect Dis. 1996;174: Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA. 1996;275: , 6ab-4

5 Gleason PP, Meehan TP, Fine JM, et al. Associations between initial antimicrobial regimens and medical outcomes for elderly patients with pneumonia. Arch Intern Med. 1999;159: Heffelfinger JD, Dowell SF, Jorgensen JH, Klugman KP, et al. Management of Community-Acquired Pneumonia in the era of pneumococcal resistance: A Report From the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Archives of Internal Medicine. 2000, 160: Houck PM, MacLehose RF, Niederman MS, Lowery JK. Empiric antibiotic therapy and mortality among Medicare pneumonia inpatients in 10 western states, 1993, 1995, and Chest. 2001;119; Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Clin Infect Dis. 2000;31: Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis March 1;44 Suppl 2:S27-72., 6ab-5

6 Pneumonia Consensus Recommendations Patient Type Non ICU Patient Recommendation -lactam (IV or IM) Table Macrolide (IV or PO) Table 2.5 Or Antipneumococcal Quinolone monotherapy (IV or PO) Table 2.9 Or -lactam (IV or IM) Table Doxycycline (IV or PO) Table 2.10 Or If less than 65 with no Risk Factors for Drug-Resistant Pneumococcus (see data element) Macrolide monotherapy (IV or PO) Table 2.5 -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam, Ertapenem Macrolide = Erythromycin, Clarithromycin, Azithromycin Antipneumococcal Quinolones = Levofloxacin 1, Moxifloxacin, Gemifloxacin, 6ab-6

7 Patient Type Recommendation ICU Patient Macrolide (IV) Table 2.6+ either -lactam (IV) Table 2.16 OR Antipneumococcal/Antipseudomonal -lactam (IV) Table 2.4 Or Antipneumococcal Quinolone (IV) Table 2.14 OR Antipseudomonal Quinolone (IV) Table either - lactam (IV) Table 2.16 OR Antipneumococcal/ Antipseudomonal -lactam (IV) Table 2.4 Or Antipneumococcal/ Antipseudomonal -lactam (IV) Table Aminoglycoside (IV) Table either Antipneumococcal Quinolone (IV) Table 2.14 Or Macrolide (IV) Table 2.6 -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam, Antipneumococcal/ Antipseudomonal -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam, Doripenem Macrolide = Erythromycin, Azithromycin Antipneumococcal Quinolones = Levofloxacin 1, Moxifloxacin Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin 1 Non-ICU patient with Pseudomonal Risk Aminoglycoside = Gentamicin, Tobramycin, Amikacin These antibiotics are acceptable for Non-ICU patients with Pseudomonal Risk ONLY: Antipneumococcal/Antipseudomonal -lactam (IV) Table Antipseudomonal Quinolone (IV or PO) Table 2.8 Or, 6ab-7

8 Patient Type Recommendation Antipseudomonal -lactam (IV) Table Aminoglycoside (IV) Table either Antipneumococcal Quinolone (IV or PO) Table 2.9 Or Macrolide (IV or PO) Table 2.5 These antibiotics are ONLY acceptable for Non-ICU patients with -lactam allergy and Pseudomonal Risk: Aztreonam (IV or IM) Table Antipneumococcal Quinolone (IV or PO) Table Aminoglycoside (IV) Table 2.11 Or Aztreonam 2 (IV or IM) Table Levofloxacin 1 (IV or PO) Table 2.17 Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin 1 Antipseudomonal -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam, Doripenem Aminoglycoside = Gentamicin, Tobramycin, Amikacin Antipneumococcal Quinolone = Levofloxacin 1, Moxifloxacin, Gemifloxacin Macrolide = Erythromycin, Clarithromycin, Azithromycin Data collected by the CMS National Pneumonia Project indicate that 78% of Medicare pneumonia patients who were hospitalized during received antibiotics that were consistent with guidelines published at that time. Among the states and territories this ranged from 55% to 87%. Compliance was lower among ICU patients, largely because atypical pathogen coverage was generally not common, but was only recommended for ICU patients. Subsequent revisions have made such coverage recommended for all inpatients.. 1 Levofloxacin should be used in 750mg dosage when used in the management of patients with pneumonia. 2 For patients with renal insufficiency. Note: The dosage listed is specified to reflect clinical expert recommendations. We do not collect dosage information for the purposes of the Pneumonia Project., 6ab-8

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11 I X Missing Healthcare Associated PN = Y B = N X Missing Compromised = 1, 2, 3 B = 4 X Missing Received = 1 or 4 D = 2 or 3 X Grid Not Populated Name 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 UTD. On Table 2.1 Route = 10 for all doses D =1, 2, 3 for any antibiotic dose For each case, include for further processing only those antibiotic doses that are on Table 2.1 and whose associated route = 1, 2, or 3. J, 6ab-11

12 J Date = UTD for all antibiotic doses D Non-UTD Value for at least one antibiotic dose Days = Date Arrival Date (in days) Calculate Days for each antibiotic dose that has a non-utd date. Proceed only with antibiotic doses that have non-utd Dates. X < 0 for ANY antibiotic dose Days None < 0 for ANY antibiotic dose Days = 0 for ALL antibiotic doses > 0 for ANY antibiotic dose Initialize Abxday flag = No for each antibiotic doses. Set Abxday flag = Yes for each antibiotic dose where Days = 0. X Missing Arrival Time =UTD Abxday flag = No for all doses D Non-UTD Value = Yes for ANY dose. Proceed with doses where Abxday flag = Yes. Time = UTD for all antibiotic doses Abxday flag = No for all doses D Non-UTD Value for at least one antibiotic dose. = Yes for ANY dose. Proceed with doses where Abxday flag = Yes. ANTIMINUTES = Date and Time - Arrival Date and Arrival Time (in minutes) Calculate ANTIMINUTES for each antibiotic dose that has a non-utd date and time combination. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. X < 0 for ANY dose ANTIMINUTES None < 0 for ANY dose ANTIMINUTES 0 and 1440 minutes for at least one antibiotic dose. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. > 1440 minutes (24 hours) for all antibiotic doses with non-utd date and time. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. Abxday flag = No for all doses =Yes for ANY dose. Proceed with doses where Abxday flag=yes. D For each case, proceed ONLY with those antibiotic doses that satisfy at least one of the following conditions: Abxday flag = Yes ANTIMINUTES 0 and 1440 ICU Admission or Transfer = 1 Allergy Missing = Y X = 2 K = N M B, 6ab-12

13 K The Patient Age is calculated from Admission Date Birthdate as part of the Initial Patient Population logic Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example: if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. Name None on Table 2.9 Name None on Table 2.5 Name None on Table 2.3 On Table 2.9 On Table 2.5 On Table 2.3 Route ALL=3 Route ALL = 3 Route ALL = 1 ANY= 1,2 ANY= 2, 3 Patient Age < 65 >= 65 Name None on Table 2.5 or 2.10 On Table 2.5 or 2.10 ANY= 1, 2 X Missing Risk Factors for Drug Resistant Pneumococcus = Y Route ALL= 3 = N ANY= 1,2 Regimen1a = True Regimen2a = True Regimen3a = True P P P Regimen 1a: All non- ICU patients Regimen 2a: non-icu patients without Drug Resistant Pneumococcus Risk Regimen 3a: All non- ICU patients L, 6ab-13

14 L Name None on Table 2.4 Name On Table 2.4 None on Table 2.4 Name On Table 2.7 None on Table 2.7 Name On Table 2.7 None on Table 2.7 On Table 2.4 Route ALL=1,3 Route ALL =1 Route ALL =1 Missing Route ANY= 2 Name On Table 2.8 Route ANY = 1,2 Pseudomonas Risk ALL=1,3 None on Table 2.8 ALL= 3 = N ANY= 2 Name On Table 2.11 Route ANY= 2 Name On Table 2.5 Route ALL = 3 None on Table 2.11 ALL=1,3 None on Table 2.5 ANY = 2,3 Name On Table 2.9 Route ANY = 1,2 Name On Table 2.11 Route ANY= 2 None on Table 2.9 ALL = 3 None on Table 2.11 ALL = 1, 3 Missing ANY = 2,3 Name On Table 2.17 Route ANY = 1,2 Pseudomonas Risk = Y None on Table 2.17 ALL = 3 = N X Name None on Table 2.9 Missing Pseudomonas Risk = N X Missing Allergy = N ANY= 1, 2 On Table 2.9 = Y = Y Route ANY = 1,2 ALL= 3 Missing Allergy = N = Y X Missing Pseudomonas Risk = N = Y Regimen4a = True = Y Regimen5a = True X Regimen6a = True Regimen7a = True P Regimen 4a: non-icu patients with Pseudomonas Risk P Regimen 5a: non-icu patients with Pseudomonas Risk Note: Regimen 5a cannot be reached if Regimen 4a is met due to the regimens overlap. P Regimen 6a: non-icu patients with Pseudomonas Risk and Beta lactam allergy Note: Regimen 6a cannot be reached if Regimen 1a is met due to the regimens overlap. P Regimen 7a: non-icu patients with Pseudomonas Risk and Beta lactam allergy O Note: Regimen 7a cannot be reached if Regimen 6a is met due to the regimens overlap., 6ab-14

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16 P Regimen1a True E False Regimen2a True E False Regimen3a True E False Regimen4a True E False Regimen5a True E False Regimen6a True E False Regimen7a True E B D D E E X False D B Not In Measure Population D In Measure Population E In Numerator Population Will Be Rejected XCase Stop, 6ab-16

17 Pneumonia (PN)- 6: Initial Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients Numerator: Denominator: Variable Key: Pneumonia patients who received an initial antibiotic regimen consistent with current guidelines during the first 24 hours of their hospitalization. Pneumonia patients 18 years of age and older. Patient Age, Duration of Stay, Days, Day (Abxday) Flag, ANTIMINUTES, Regimen 1a, Regimen 2a, Regimen 3a, Regimen 4a, Regimen 5a, Regimen 6a, Regimen 7a. 1. Start Run cases that are included in the Pneumonia (PN) Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this measure. 2. Check Chest X-Ray a. If Chest X-Ray is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Chest X-Ray equals 2 or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Chest X-Ray equals 1, continue processing and proceed to Comfort Measures Only. 3. Check Comfort Measures Only a. If Comfort Measures Only is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Comfort Measures Only equals 1, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Comfort Measures Only equals 2, 3, or 4, continue processing and proceed to Clinical Trial. 4. Check Clinical Trial a. If Clinical Trial is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Clinical Trial equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the measure population. Stop, 6ab-17

18 c. If Clinical Trial equals No, continue processing and proceed to Initialize Variables. 5. Initialize Variables. Initialize Variables as follows: Regimen 1a equal to false. Regimen 2a equal to false. Regimen 3a equal to false. Regimen 4a equal to false. Regimen 5a equal to false. Regimen 6a equal to false. Regimen 7a equal to false. Proceed to Transfer From Another Hospital or ASC. 6. Check Transfer From Another Hospital or ASC a. If Transfer From Another Hospital or ASC is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Transfer From Another Hospital or ASC equals 1, 2, 3, or 4, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Transfer From Another Hospital or ASC equals 5, continue processing and proceed to Pneumonia Diagnosis: ED/Direct Admit. 7. Check Pneumonia Diagnosis: ED/Direct Admit a. If Pneumonia Diagnosis: ED/Direct Admit is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pneumonia Diagnosis: ED/Direct Admit equals 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Pneumonia Diagnosis: ED/Direct Admit equals 1, 2, or 4, continue processing and proceed to ICU Admission or Transfer. 8. Check ICU Admission or Transfer a. If ICU Admission or Transfer is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If ICU Admission or Transfer equals 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If ICU Admission or Transfer equals 1 or 2, continue processing and proceed to recheck Pneumonia Diagnosis: ED/Direct Admit 9. Recheck Pneumonia Diagnosis: ED/Direct Admit a. If Pneumonia Diagnosis: ED/Direct Admit equals 4, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop, 6ab-18

19 b. If Pneumonia Diagnosis: ED/Direct Admit equals 1 or 2, continue processing and proceed to Arrival Date. 10. Check Arrival Date a. If the Arrival Date is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If the Arrival Date equals Unable to Determine, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop c. If the Arrival Date equals a Non Unable to Determine Value, continue processing and proceed to the Duration of Stay calculation. 11. Calculate Duration of Stay. Duration of Stay, in days, is equal to the Discharge Date minus the Arrival Date. 12. Check Duration of Stay a. If the Duration of Stay is less than or equal to 1, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop b. If the Duration of Stay is greater than 1, continue processing and proceed to Health Care Associated Pneumonia (PN). 13. Check Health Care Associated PN a. If Health Care Associated PN is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Health Care Associated PN equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Health Care Associated PN equals No, continue processing and proceed to Compromised., 6ab-19

20 14. Check Compromised a. If Compromised is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Compromised equals 1, 2, or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Compromised equals 4, continue processing and proceed to Received. 15. Check Received a. If Received is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Received equals 1 or 4, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop c. If Received equals 2 or 3, continue processing and proceed to Name. 16. Check Name a. If the Grid is not populated, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If the Name is on Table 2.1, continue processing and proceed to Route. 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 Unable to Determine. 17. Check Route a. If the Route is equal to 10 for all doses, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop b. If the Route is equal to 1, 2 or 3 for any antibiotic dose, continue For each case, include for further processing only those antibiotic does that are on Table 2.1 and whose associated route equals 1, 2 or 3. Proceed to Date. 18. Check Date a. If the Date equals Unable to Determine for all antibiotic doses, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop, 6ab-20

21 b. If the Date equals a Non Unable to Determine Value for at least one antibiotic dose, continue processing and proceed to the Days calculation. 19. Calculate the Days. The Days, in days, equals the Date minus the Arrival Date. Calculate the Days for each antibiotic dose that has a non Unable to Determine date. Proceed only with antibiotic doses that have non Unable to Determine Dates. 20. Check Days a. If the Days is less than zero for ANY antibiotic dose, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If none of the Days is less than zero for ANY antibiotic dose, continue processing and recheck Days. 21. Recheck Days a. If the Days is equal to zero for ALL antibiotic doses, continue processing and proceed to step 29 and recheck ICU Admission or Transfer. Do not check Arrival Time, Time, and ANTIMINUTES. b. If the Days is greater than zero for ANY antibiotic dose, continue processing and proceed to Initialize Abxday Flag 22. Initialize Abxday Flag only if Days was greater than zero for any antibiotic dose. Initialize Abxday Flag to equal No for each antibiotic doses. Set Abxday flag to equal Yes for each antibiotic dose where Days is equal to zero. 23. Check Arrival Time a. If the Arrival Time is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If the Arrival Time equals Unable to Determine, continue processing and check the Abxday flag. 1. If the Abxday flag equals No for all doses, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop 2. If the Abxday flag equals Yes for Any dose, continue Proceed only with those doses where the Abxday flag equals Yes. Proceed to step 29 and recheck ICU Admission or Transfer. Do not check Time or ANTIMINUTES., 6ab-21

22 c. If the Arrival Time equals a Non Unable To Determine Value, continue processing and proceed to Time. 24. Check Time only if the Arrival Time is a Non Unable to Determine Value a. If the Time is equal to Unable to Determine for all antibiotic doses, continue processing and check the Abxday flag. 1. If the Abxday flag is equal to No for all doses, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop 2. If the Abxday flag is equal to Yes for ANY dose, continue Proceed only with doses where the Abxday flag is equal to Yes. Proceed to step 29 and recheck ICU Admission or Transfer. Do not check ANTIMINUTES. b. If the Time is a Non Unable to Determine value for at least one antibiotic dose, continue processing and proceed to the ANTIMINUTES calculation. 25. Calculate ANTIMINUTES only if the Time is a Non Unable to Determine Value. ANTIMINUTES, in minutes, is equal to the Date and Time minus the Arrival Date and the Arrival Time. Calculate the ANITMINUTES for each antibiotic dose that has a non Unable to Determine date and time combination. Proceed with antibiotic doses that have ANTIMINUTES calculated OR Abxday flag is equal to Yes. 26. Check ANTIMINUTES a. If the ANTIMINUTES are less than zero for ANY antibiotic dose, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If none of the ANTIMINUTES is less than zero for ANY antibiotic dose, continue processing and recheck ANTIMINUTES. 27. Recheck ANTIMINUTES a. If the ANTIMINUTES are greater than 1440 minutes or 24 hours for all antibiotic doses with a Non Unable To Determine date and time, continue Proceed with antibiotic doses that have ANTIMINUTES calculated or Abxflag equal to Yes. Proceed to the Abxday flag. 1. If the Abxday flag is equal to No for all doses, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop, 6ab-22

23 2. If the Abxday flag is equal to Yes for ANY dose, continue Proceed only with doses where the Abxday flag is equal to Yes. Proceed to recheck ICU Admission or Transfer. b. If the ANTIMINUTES are greater than or equal to zero and less than or equal to 1440 minutes for at least one antibiotic dose, continue Proceed only with antibiotic doses that have ANTIMINUTES calculated or Abxday Flag equal to Yes. Proceed to recheck ICU Admission or Transfer. 28. For each case, proceed ONLY with those antibiotic doses that satisfy at least one of the following conditions: Abxday flag is equal to Yes or ANTIMINUTES is greater or equal to zero and less than or equal to Proceed to recheck ICU Admission or Transfer. 29. Recheck ICU Admission or Transfer a. If ICU Admission or Transfer equals 1, continue processing and check Allergy. Check Allergy. 1. If Allergy is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop 2. If Allergy equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop 3. If Allergy equals No, continue processing and proceed to step 77 and check Route. Do not check Regimen 1a, 2a, 3a, 4a, 5a, 6a, or 7a. b. If ICU Admission or Transfer equals 2, continue processing and proceed to check Regimen 1a. 30. Non ICU Regimens 31. Check Regimen 1a: All non ICU patients 32. Check Name a. If None of the Names are on Table 2.9, continue processing and proceed to step 34 and check Regimen 2a. b. If the Name is on Table 2.9, continue processing and proceed to Route. 33. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only., 6ab-23

24 a. If ALL of the Routes are equal to 3, continue processing and proceed to Regimen 2a. b. If ANY of the Routes are equal to 1 or 2, set Regimen 1a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 2a, 3a, 4a, 5a, 6a, 7a. 34. Check Regimen 2a: Non ICU patients without Drug Resistant Pneumococcus Risk 35. Check Name a. If None of the Names are on Table 2.5, continue processing and proceed to step 39 and check Regimen 3a. b. If the Name is on Table 2.5, continue processing and proceed to Route. 36. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 3, continue processing and proceed to step 39 and check Regimen 3a. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to Patient Age. 37. Check Patient Age. The Patient Age is calculated from Admission Date minus Birthdate as part of the Initial Patient Population logic. a. If the Patient Age is greater than or equal to 65, continue processing and proceed to step 39 and check Regimen 3a. b. If the Patient Age is less than 65, continue processing and proceed to Risk Factors for Drug Resistant Pneumococcus. 38. Check Risk Factors for Drug Resistant Pneumococcus a. If Risk Factors for Drug Resistant Pneumococcus are missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Risk Factors for Drug Resistant Pneumococcus equal Yes, continue processing and proceed to step 39 and check Regimen 3a. c. If Risk Factors for Drug Resistant Pneumococcus equal No, set Regimen 2a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 3a, 4a, 5a, 6a, 7a. 39. Check Regimen 3a: All non ICU patients, 6ab-24

25 40. Check Name a. If None of the Names are on Table 2.3, continue processing and proceed to step 44 and check Regimen 4a. b. If the Name is on Table 2.3, continue processing and proceed to Route. 41. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 1, continue processing and proceed to step 44 and check Regimen 4a. b. If ANY of the Routes are equal to 2 or 3, continue processing and proceed to recheck Name. 42. Recheck Name a. If None of the Names are on Table 2.5 or Table 2.10, continue processing and proceed to step 44 and check Regimen 4a. b. If the Name is on Table 2.5 or Table 2.10, continue processing and proceed to recheck Route. 43. Recheck Route a. If ALL of the Routes are equal to 3, continue processing and proceed to step 44 and recheck Regimen 4a. b. If ANY of the Routes are equal to 1 or 2, set Regimen 3a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 4a, 5a, 6a, 7a. 44. Check Regimen 4a: non ICU patients with Pseudomonas Risk 45. Check Name a. If None of the Names are on Table 2.4, continue processing and proceed to step 50 and check Regimen 5a. b. If the Name is on Table 2.4, continue processing and proceed to Route. 46. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 1 or 3, continue processing and proceed to step 50 and check Regimen 5a., 6ab-25

26 b. If ANY of the Routes are equal to 2, continue processing and proceed to recheck Name. 47. Recheck Name a. If None of the Names are on Table 2.8, continue processing and proceed to step 50 and check Regimen 5a. b. If the Name is on Table 2.8, continue processing and proceed to recheck Route. 48. Recheck Route a. If ALL of the Routes are equal to 3, continue processing and proceed to step 50 and check Regimen 5a. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to Pseudomonas Risk. 49. Check Pseudomonas Risk a. If Pseudomonas Risk is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pseudomonas Risk equals No, continue processing and proceed to step 50 and check Regimen 5a. c. If Pseudomonas Risk equals Yes, set Regimen 4a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 5a, 6a, 7a. 50. Check Regimen 5a: non ICU patients with Pseudomonas Risk 51. Check Name a. If None of the Names are on Table 2.4, continue processing and proceed to step 60 and check Regimen 6a. b. If the Name is on Table 2.4, continue processing and proceed to Route. 52. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 1 or 3, continue processing and proceed to step 60 and check Regimen 6a. b. If ANY of the Routes are equal to 2, continue processing and proceed to recheck Name. 53. Recheck Name, 6ab-26

27 a. If None of the Names are on Table 2.11, continue processing and proceed to step 60 and check Regimen 6a. b. If the Name is on Table 2.11, continue processing and proceed to recheck Route. 54. Recheck Route a. If ALL of the Routes are equal to 1 or 3, continue processing and proceed to step 60 and check Regimen 6a. b. If ANY of the Routes are equal to 2, continue processing and proceed to recheck Name. 55. Recheck Name a. If None of the Names are on Table 2.5, continue processing and proceed to step 57 and recheck Name. Do not recheck Route. b. If the Name is on Table 2.5, continue processing and proceed to recheck Route. 56. Recheck Route. a. If ALL of the Routes are equal to 3, continue processing and proceed to recheck Name. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to step 59 and check Pseudomonas Risk. Do not recheck Name and Route. 57. Recheck Name a. If None of the Names are on Table 2.9, continue processing and proceed to step 60 and check Regimen 6a. b. If the Name is on Table 2.9, continue processing and proceed to recheck Route. 58. Recheck Route. a. If ALL of the Routes are equal to 3, continue processing and proceed to step 60 and check Regimen 6a. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to Pseudomonas Risk. 59. Check Pseudomonas Risk a. If Pseudomonas Risk is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pseudomonas Risk equals No, continue processing and proceed to Regimen 6a., 6ab-27

28 c. If Pseudomonas Risk equals Yes, set Regimen 5a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 6a, 7a. Note: Regimen 5a cannot be reached if Regimen 4a is met due to the regimens overlap. 60. Check Regimen 6a: non ICU patients with Pseudomonas Risk and Beta lactam allergy 61. Check Name a. If None of the Names are on Table 2.7, continue processing and proceed to step 69 and check Regimen 7a. b. If the Name is on Table 2.7, continue processing and proceed to Route. 62. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 1, continue processing and proceed to step 69 and check Regimen 7a. b. If ANY of the Routes are equal to 2 or 3, continue processing and proceed to recheck Name. 63. Recheck Name a. If None of the Names are on Table 2.9, continue processing and proceed to step 69 and check Regimen 7a. b. If the Name is on Table 2.9, continue processing and proceed to recheck Route. 64. Recheck Route a. If ALL of the Routes are equal to 3, continue processing and proceed to step 69 and check Regimen 7a. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to recheck Name. 65. Recheck Name a. If None of the Names are on Table 2.11, continue processing and proceed to step 69 and check Regimen 7a. b. If the Name is on Table 2.11, continue processing and proceed to recheck Route. 66. Recheck Route, 6ab-28

29 a. If ALL of the Routes are equal to 1 or 3, continue processing and proceed to step 69 and check Regimen 7a. b. If ANY of the Routes are equal to 2, continue processing and proceed to Pseudomonas Risk. 67. Check Pseudomonas Risk a. If Pseudomonas Risk is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pseudomonas Risk equals No, continue processing and proceed to step 69 and check Regimen 7a. Do not check Allergy. c. If Pseudomonas Risk equals Yes, continue processing and proceed to Allergy. 68. Check Allergy a. If Allergy is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Allergy equals No, continue processing and proceed to Regimen 7a. c. If Allergy equals Yes, set Regimen 6a to equal True. Continue processing and proceed to step 85 and check the Regimens. Do not check Regimen 7a. Note: Regimen 6a cannot be reached if Regimen 1a is met due to the regimens overlap. 69. Check Regimen 7a: non ICU patients with Pseudomonas Risk and Beta lactam allergy 70. Check Name a. If None of the Names are on Table 2.7, continue processing and proceed to step 84 and check Another Source of Infection. b. If the Name is on Table 2.7, continue processing and proceed to Route. 71. Check Route Note: When checking for route of antibiotic, check ONLY for the corresponding antibiotic. For example, if an antibiotic on Table 2.9 was received by the patient, check if route was appropriate for that antibiotic only. a. If ALL of the Routes are equal to 1, continue processing and proceed to step 84 and check Another Source of Infection. b. If ANY of the Routes are equal to 2 or 3, continue processing and proceed to recheck Name., 6ab-29

30 72. Recheck Name a. If None of the Names are on Table 2.17, continue processing and proceed to step 84 and check Another Source of Infection. b. If the Name is on Table 2.17, continue processing and proceed to recheck Route. 73. Recheck Route a. If ALL of the Routes are equal to 3, continue processing and proceed to step 84 and check Another Source of Infection. b. If ANY of the Routes are equal to 1 or 2, continue processing and proceed to Pseudomonas Risk. 74. Check Pseudomonas Risk a. If Pseudomonas Risk is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pseudomonas Risk equals No, continue processing and proceed to step 84 and check Another Source of Infection. c. If Pseudomonas Risk equals Yes, continue processing and proceed to Allergy. 75. Check Allergy a. If Allergy is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Allergy equals No, continue processing and proceed to step 84 and check Another Source of Infection. c. If Allergy equals Yes, set Regimen 7a to equal True. Continue processing and proceed to step 85 and check the Regimens. 76. ICU Regimens 77. Check Route a. If ALL of the Routes are equal to 1 or 3, continue processing and proceed to step 84 and check Another Suspected Source of Infection. b. If ANY of the Routes are equal to 2, continue processing and proceed to recheck Name. Proceed further with only those antibiotic doses where route equals 2 (intravenous). 78. Check Name a. If None of the Names are on Table 2.4 or 2.16 continue processing and proceed to step 81 and recheck Name. b. If the Name is on Table 2.4 or 2.16 continue processing and proceed to recheck Name., 6ab-30

31 79. Recheck Name a. If the Name is on Table 2.6 the case will go to Measure Category Assignment of E and will be in the Numerator Population. Stop Regimen 1b: All ICU patients: Macrolide (Intravenous) plus Beta lactam (Intravenous) or Antipneumococcal/Antipseudomonal Beta lactam (Intravenous) b. If the Name is not on Table 2.6 continue processing and recheck Name. 80. Recheck Name a. If None of the Names are on Tables 2.14 or 2.8, continue processing and proceed to step 81 and recheck Name. b. If the Name is on Tables 2.14 or 2.8, the case will go to Measure Category Assignment of E and will be in the Numerator Population. Stop Regimen 2b: All ICU patients: Antipneumococcal Quinolone (Intravenous) OR Antipseudomonal Quinolone (Intravenous) plus Beta lactam (Intravenous) OR Antipneumococcal/Antipseudomonal beta lactam (Intravenous). 81. Recheck Name a. If None of the Names are on Table 2.4, continue processing and proceed to step 84 and check Another Source of Infection. b. If the Name is on Table 2.4, continue processing and proceed to recheck Name. 82. Recheck Name a. If None of the Names are on Table 2.11, continue processing and proceed to step 84 and check Another Source of Infection. b. If the Name is on Table 2.11, continue processing and recheck Name. 83. Recheck Name a. If None of the Names are on Table 2.6 or 2.14, continue processing and proceed to step 84 and check Another Source of Infection. b. If the Name is on Table 2.6 or 2.14, the case will go to Measure Category Assignment of E and will be in the Numerator Population. Stop Regimen 3b: All ICU patients: Antipneumococcal/Antipseudomonal beta lactam (Intravenous) plus Aminoglycoside (Intravenous) plus either Antipneumococcal Quinolone (Intravenous) OR Macrolide (Intravenous) NOTE: Regimen 3b cannot be reached since the patient will pass the measure if either Regimen 1b or 2b are met due to the regimens overlap., 6ab-31

32 84. Check Another Source of Infection a. If Another Source of Infection is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Another Source of Infection equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Another Source of Infection equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop 85. Check Regimen 1a a. If Regimen 1a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 1a is equal to False, continue processing and proceed to check Regimen 2a. 86. Check Regimen 2a a. If Regimen 2a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 2a is equal to False, continue processing and proceed to check Regimen 3a. 87. Check Regimen 3a a. If Regimen 3a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 3a is equal to False, continue processing and proceed to check Regimen 4a. 88. Check Regimen 4a a. If Regimen 4a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 4a is equal to False, continue processing and proceed to check Regimen 5a. 89. Check Regimen 5a a. If Regimen 5a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop, 6ab-32

33 b. If Regimen 5a is equal to False, continue processing and proceed to check Regimen 6a. 90. Check Regimen 6a a. If Regimen 6a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 6a is equal to False, continue processing and proceed to check Regimen 7a. 91. Check Regimen 7a a. If Regimen 7a is equal to True, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop b. If Regimen 7a is equal to False, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop, 6ab-33

34 , 6ab-34

35 , 6ab-35

36 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 UTD. a I a X Missing Healthcare Associated PN = Y a B = N a X Missing Compromised = 1, 2, 3 a B = 4 a X Missing Received = 1 or 4 a D = 2 or 3 a X Grid Not Populated Name On Table 2.1 Route = 10 for all doses a D = 1,2,3 for any antibiotic dose For each case, include for further processing only those antibiotic doses that are on Table 2.1 and whose associated route = 1, 2, or 3. a J, 6ab-36

37 a J Date =UTD for all antibiotic doses a D Non-UTD Value for at least one antibiotic dose Days = Date Arrival Date (in days) Calculate Days for each antibiotic dose that has a non-utd date. Proceed only with antibiotic doses that have non-utd Dates. a X < 0 for ANY antibiotic dose Days None < 0 for ANY antibiotic dose Days = 0 for ALL antibiotic doses a K > 0 for ANY antibiotic dose Initialize Abxday flag = No for each antibiotic doses. Set Abxday flag = Yes for each antibiotic dose where Days = 0. a X Missing Arrival Time =UTD Abxday flag = No for all doses a D Non-UTD Value =Yes for ANY dose. Proceed with Doses where Abxday flag=yes. Time =UTD for all antibiotic doses Abxday flag = No for all doses a D Non-UTD Value for at least one antibiotic dose ANTIMINUTES = Date and Time - Arrival Date and Arrival Time (in minutes) Calculate ANTIMINUTES for each antibiotic dose that has a non-utd date and time combination. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. =Yes for ANY dose. Proceed with doses where Abxday flag=yes. a X < 0 for ANY antibiotic dose ANTIMINUTES None < 0 for ANY dose ANTIMINUTES > 1440 minutes (24 hours) for all antibiotic doses with non-utd date and time. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. Abxday flag = No for all doses a D 0 and 1440 minutes for at least one antibiotic dose. Proceed with antibiotic doses that have ANTIMINUTES calculated, OR Abxday flag = Yes. =Yes for ANY dose. Proceed with doses where Abxday flag=yes. For each case, proceed ONLY with those antibiotic doses that satisfy at least one of the following conditions: Abxday flag = Y ANTIMINUTES 0 and 1440 a K, 6ab-37

38 , 6ab-38

39 Pneumonia (PN)-6a: Initial Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients Intensive Care Unit (ICU) Patients Numerator: Denominator: Variable Key: ICU pneumonia patients who received an initial antibiotic regimen consistent with current guidelines during the first 24 hours of their hospitalization. ICU pneumonia patients 18 years of age and older. Duration of Stay, Days, ANTIMINUTES, Day (Abxday) Flag 1. Start Run cases that are included in the Pneumonia (PN) Initial Patient Population and pass the edits defined in the Transmission Data Processing Flow: Clinical through this measure. 2. Check Chest X-Ray a. If Chest X-Ray is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Chest X-Ray equals 2 or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Chest X-Ray equals 1, continue processing and proceed to Comfort Measures Only. 3. Check Comfort Measures Only a. If Comfort Measures Only is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Comfort Measures Only equals 1, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Comfort Measures Only equals 2, 3, or 4, continue processing and proceed to Clinical Trial. 4. Check Clinical Trial a. If Clinical Trial is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Clinical Trial equals Yes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop, 6ab-39

40 c. If Clinical Trial equals No, continue processing and proceed to Transfer From Another Hospital or ASC 5. Check Transfer From Another Hospital or ASC a. If Transfer From Another Hospital or ASC is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Transfer From Another Hospital or ASC equals 1, 2, 3, or 4, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Transfer From Another Hospital or ASC equals 5, continue processing and proceed to Pneumonia Diagnosis: ED/Direct Admit. 6. Check Pneumonia Diagnosis: ED/Direct Admit a. If Pneumonia Diagnosis: ED/Direct Admit is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If Pneumonia Diagnosis: ED/Direct Admit equals 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If Pneumonia Diagnosis: ED/Direct Admit equals 1, 2, or 4, continue processing and proceed to ICU Admission or Transfer. 7. Check ICU Admission or Transfer a. If ICU Admission or Transfer is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop b. If ICU Admission or Transfer equals 2 or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop c. If ICU Admission or Transfer equals 1, continue processing and proceed to recheck Pneumonia Diagnosis: ED/Direct Admit., 6ab-40