Measure Information Form

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1 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 #: SCIP- Set Measure ID # 2a 2b 2c 2d 2e 2f 2g 2h Performance Measure Prophylactic Selection for Surgical Patients - Overall Rate Prophylactic Selection for Surgical Patients - CG Prophylactic Selection for Surgical Patients Other Cardiac Surgery Prophylactic Selection for Surgical Patients - Hip rthroplasty Prophylactic Selection for Surgical Patients - Knee rthroplasty 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 Description: Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure) Rationale: 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 s: n increase in the rate Specifications Manual for National SCIP-Inf 2-1

2 Numerator Statement: Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure. Included populations: Not pplicable xcluded Populations: None Data lements: dministration llergy Oral s Vancomycin The antibiotic regimens described in the table which follows later in this section reflect the combined, published recommendations of the merican Society of Health-System Pharmacists, the Medical Letter, the Infectious Diseases Society of merica, the Sanford Guide to ntimicrobial Therapy 2001, and the Surgical Society. 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 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 documented infection prior to surgical procedure of interest Patients whose procedure of interest occurred prior to date of admission Specifications Manual for National SCIP-Inf 2-2

3 Data lements: dmission Date dmission Diagnosis of dministration Date dministration Time s During Stay s Prior to rrival irthdate arly s ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code Prior to nesthesia Procedure of Surgery nd Date Surgery nd Time 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 and 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 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, their assistants, hospital committees (i.e., Q, Control, Pharmacy and Therapeutics, Surgical Section Subcommittees, etc.) any of which may choose to address this physician practice issue as part of a larger surgical infection prevention initiative. Sampling: Yes, for additional information see the Sampling Section. Data Reported as: Overall aggregate rate for all surgeries and stratified rates by data element Procedure of, generated from count data reported as a proportion 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): Mangram J, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, Infect Control Hosp pidemiol. 1999;20: Specifications Manual for National SCIP-Inf 2-3

4 merican Society of Health-System Pharmacists. SHP therapeutic guidelines on antimicrobial prophylaxis in surgery. m J Health Syst Pharm. 1999;56: The Medical Letter. ntimicrobial prophylaxis in surgery. Med Lett Drugs Ther. 1999;41: Dellinger P, Gross P, arrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18: Gilbert DN, Moellering RC Jr., Sande M, eds. The Sanford Guide to ntimicrobial Therapy. 31 st ed. Hyde Park, VT: ntimicrobial Therapy, Inc; 2001.pp Page CP, ohnen JM, Fletcher JR, et al. ntimicrobial prophylaxis for surgical wounds. rch Surg. 1993;128: Specifications Manual for National SCIP-Inf 2-4

5 Prophylactic Regimen Selection for Surgery Surgical Procedure CG, Other Cardiac or Vascular Hip/Knee rthroplasty Colon pproved s Cefazolin, Cefuroxime, Cefamandole 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 Oral: after effective mechanical bowel preparation, Neomycin Sulfate Table rythromycin ase Table 3.4 OR Neomycin Sulfate Table Metronidazole Table 3.4 dministered for 18 hours preoperatively Parenteral: Cefotetan, Cefoxitin, Cefmetazole, or mpicillin/sulbactam Table 3.5 OR Cefazolin Table Metronidazole Table 3.6a Hysterectomy Special Considerations If β-lactam allergy: Clindamycin Table Gentamicin Table 3.11, or Clindamycin Table Quinolone Table 3.12, or Clindamycin Table ztreonam Table 2.7 OR Metronidazole Table 3.6a with Gentamicin Table 3.11, or Metronidazole Table 3.6a + Quinolone Table 3.12 Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or mpicillin/sulbactam Table 3.7 If β-lactam allergy: Clindamycin Table Gentamicin Table 3.11, or Clindamycin Table Quinolone Table 3.12 or Clindamycin Table ztreonam Table 2.7 OR Metronidazole Table 3.6a + Gentamicin Table 3.11, or Metronidazole Table 3.6a + Quinolone Table 3.12 OR Clindamycin monotherapy Table 3.9 *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 documented justification for its use (see data element Vancomycin) Specifications Manual for National SCIP-Inf 2-5

6 SCIP-: Prophylactic Selection for Surgical Patients Numerator: Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure. Denominator: ll selected surgical patients with no evidence of prior infection. Variable Key: ll Invalid Start ICD-9-CM Principal or Other Procedure Code ll Missing or None on Table 5.10 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. Patient ge Days I Timing I Surgery Days Surgery Match t least one on Table 5.10 Missing /Invalid dmission Date Valid irthdate Valid Patient ge(in years) = dmission Date - irthdate Stratification Table: Set# Stratified y * Procedure Of (llowable Value) SCIP-Inf2a Overall Rate ** SCIP-Inf2b CG Table 5.01 SCIP-Inf2c Other Cardiac Surgery Table 5.02 SCIP-Inf2d Hip rthroplasty Table 5.04 SCIP-Inf2e Knee rthroplasty 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 ' Procedure of. ach case will be stratified according to the procedure code for that Procedure of, 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 Note: The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age. 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 Procedure of 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 Procedure of 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 2-6

7 H ICD-9-CM Principal Diagnosis On Table 5.09 Code Not on Table 5.09 Surgery Start Date Valid Surgery Days (in days) = Surgery Start Date dmission Date Surgery Days < 0 0 Missing /Invalid dmission Diagnosis of = Y Surgery Performed During Stay = Y Missing /Invalid Prior to nesthesia = Y s Prior To rrival = Y Procedure Of On Table 5.03 Not on Table 5.03 Missing/ Invalid Oral s s During Stay Missing / Invalid =Y s During Stay = Y =Y arly s =Y Procedure Of =Not on Table 5.03 I On Table 5.03 Specifications Manual for National SCIP-Inf 2-7

8 I Missing /Invalid for all antibiotic doses On Table 2.1 Note: Only proceed with antibiotic doses with valid name. Check against the list of antibiotics on Table 2.1 in ppendix C. for all antibiotic doses dministration Date Valid for at least one dose of an antibiotic Note: Proceed only with antibiotic doses that have valid dates. Days I = Surgery Start Date - dministration Date (in days) Days I > 1 for at least one antibiotic dose 1 for all antibiotic doses Days I < 0 for all antibiotic doses J 0 for any antibiotic dose Missing / Invalid Surgical Incision Time Valid for all antibiotic doses dministration Time Note: Proceed only with antibiotic doses that have valid times. Valid for at least one dose of antibiotic Timing I = Surgery Start Date and Surgical Incision Time - dministration Date and Time (in minutes) Timing I > 1440 minutes for any antibiotic dose Procedure Of Not on Table minutes for all antibiotic doses On Table 5.03 J Missing/ Invalid Oral s =Y J Specifications Manual for National SCIP-Inf 2-8

9 J Surgery nd Date Valid Days II = dministration Date - Surgery nd Date (in days) Days II 0 for all doses of all K > 0 for at least one dose of any Surgery nd Time Valid for all doses dministration Time Valid for at least one dose. Proceed only with antibiotic doses that have valid times. Timing II = dministration Date and Time - Surgery nd Date and Surgery nd Time (in minutes) Timing II 1440 minutes for at least one dose of NY > 1440 minutes for all doses of all s From this point, include for each case, only those antibiotic doses with Days II 0 and/or timing II 1440 for further processing Not in Measure Population O For Overall Rate (a) K Specifications Manual for National SCIP-Inf 2-9

10 K Procedure of 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 for all doses dministration = 1, 3, 4, 5, 7-10 for all doses of all s D = 2 for any dose of any Note: For each case include only those antibiotics with routes IV for further processing Procedure of 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 Procedure of 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 SCIP-Inf 2-10

11 L s Prior to rrival = Y Oral s = Y Note: In this step, only cases who received Oral s prior to arrival and atleast one dose of a during stay with Day II <=0 or Timing II <=1440 minutes will be sent to category. =N Missing /Invalid for all antibiotic doses dministration = 3, 4, 5, 7-10 for all doses M =1,2 for any dose Note: Proceed only with s that were administered either by Oral or by IV routes. Note: If the dministration check follows, the route should be checked only for that preceding antibiotic dose. For example, if an antibiotic dose was present on a specific medication table, check the route only for that corresponding antibiotic dose. On Table 3.3 dministration = 1 On Table 3.4 dministration = 1 Not on Table 3.3 = 2 Not on Table 3.4 = 2 On Table 3.5 dministration = 2 Not on Table 3.5 = 1 On Table On Table 3.6 dministration =2 dministration = 2 3.6a Not on Table 3.6 =1 Not on Table 3.6a =1 M Specifications Manual for National SCIP-Inf 2-11

12 M dministration = 1, 3,4,5, 7-10 for all doses of all s D Note: For each case include only those antibiotics with routes IV for further processing =2 Procedure of On Tables 5.01, 5.02, 5.04, 5.05, 5.08 None on Table 3.8 and None on Table 3.9 t least one on Table 3.8 or 3.9 llergy =Y =N On Tables 5.03, 5.06, 5.07 D None on Table 3.8 Missing or Invalid Measure Population Data Missing/ Invalid llergy D ny = 9 t least one on Table 3.8 Vancomycin Missing/ Invalid For Overall Rate (a) C Missing or Invalid Numerator Data N = Y Not on Table 3.9 t least one on Table 3.9 Not on Tables 3.11 or 3.12 or 2.7 t least one on Tables 3.11 or 3.12 or 2.7 =1,2,3,4,5,6,7,8 only N None on Table 3.6a Procedure of t least one on Table 3.6a Not on Tables 3.11 or 3.12 On Table 5.06, 5.07 t least one on Tables 3.11 or 3.12 t least one on Table 3.9 In Numerator Population For Overall Rate (a) D D On Table 5.03 Not on Table 3.9 Measure Population DIn For Overall Rate (a) N STOP HR FOR CMS. CONTINU FOR JCHO. Specifications Manual for National SCIP-Inf 2-12

13 For all Stratified Measures (b-h) N 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 For Stratified Measure SCIP-b Procedure of 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 For Stratified Measure SCIP -c Procedure of 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 For Stratified Measure SCIP -d Procedure of 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 O Specifications Manual for National SCIP-Inf 2-13

14 O For Stratified Measure SCIP-e Procedure of 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 For Stratified Measure SCIP-f Procedure of 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 For Stratified Measure SCIP-g Procedure of 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 For Stratified Measure 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 2-14