Measure Information Form Collected For: CMS Voluntary Only The Joint Commission - Retired Last Updated: Version 4.3a Measure Set: Pneumonia (PN) Set Measure I #: Performance Measure Name: lood Cultures Performed in the Emergency epartment Prior to Initial Antibiotic Received in Hospital escription: Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. This measure focuses on the treatment provided to Emergency epartment patients prior to admission orders. Rationale: Although recommendations for blood cultures are controversial due to the overall low yield, they can have a significant impact on the care of an individual patient and are important for epidemiologic reasons, such as antibiotic susceptibility patterns used to develop treatment guidelines. The Joint ISA/ATS Guidelines on the Management of Community-Acquired Pneumonia (CAP) in Adults recommend that certain patients with pneumonia should be investigated for specific pathogens that would significantly alter decisions regarding empirical therapy, when the presence of these pathogens is suspected (Mandell, 2007). The guidelines recommend that pretreatment blood samples for culture should be obtained from hospitalized pneumonia patients who are admitted to the Intensive Care Unit, have cavitary infiltrates, leukopenia, chronic severe liver disease, asplenia, plural effusion, have a positive pneumococcal urinary antigen test (UAT), and have active alcohol abuse (Mandell, 2007). Pretreatment cultures are recommended because the yield of clinically useful information is greater if the culture is collected before antibiotics are administered. In a large retrospective study of blood cultures in pneumonia patients, Metersky et al demonstrated that when patients are selected appropriately, for example, those who are sicker or have co-morbid conditions like liver disease, etc., the yield of blood culture pathogens was doubled for each risk factor. The study also demonstrated that doing cultures after antibiotics were given decreased yield by 50%. This measure focuses on treatment provided in the Emergency epartment where the largest number and variety of pneumonia patients receive treatment prior to admission orders. A review of performance measure data from the pneumonia national hospital quality measures over the past few years indicates that 68 to 70% of patients admitted to the hospital for pneumonia receive care and services in the E prior to admission. Emergency epartments serve patients with a variety of co-morbidities such as those indicated above and varying levels of severity related to their clinical condition. The E also serves as a triage point for the next level of care; intensive care, or general unit. In concordance with the guideline recommendations, the performance measure does not -1
require blood cultures for all E patients, but if a culture is done, it must be done prior to administration of the first dose of antibiotics received in the hospital in order to meet the intent of this measure. Type of Measure: Process Improvement Noted As: An increase in the rate Numerator Statement: Number of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics. Included Populations: Not Applicable Excluded Populations: None ata Elements: Antibiotic Administration ate Antibiotic Administration Time Antibiotic Name Arrival ate Arrival Time lood Culture Collected Initial lood Culture Collection ate Initial lood Culture Collection Time enominator Statement: Pneumonia patients 18 years of age and older who have an initial blood culture collected as an emergency department patient. Included Populations: ischarges with: An IC-9-CM Principal iagnosis Code of pneumonia as defined in Appendix A, Table 3.1 OR IC-9-CM Principal iagnosis Code of septicemia or respiratory failure (acute or chronic) as defined in Appendix A, Tables 3.2 or 3.3 AN An IC-9-CM Other iagnosis 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 day of or day after arrival -2
Patients enrolled in clinical trials Patients not admitted through the E Patients who had no diagnosis of pneumonia either as the E final diagnosis/impression or direct admission diagnosis/impression Patients who only received antibiotics prior to hospital arrival Patients who do not receive any antibiotics within 24 hours after arrival Patients who do not receive a blood culture Patients who do not have a blood culture collected in the E prior to admission order Patients who have a blood culture collected within 24 hours prior to hospital arrival Patients discharged to another hospital on day of or day after arrival Patients who left against medical advice on day of or day after arrival Patients who expired on day of or day after arrival ata Elements: Admission ate Antibiotic Received irthdate Chest -ray Clinical Trial Comfort Measures Only ischarge ate ischarge isposition IC-9-CM Other iagnosis Codes IC-9-CM Principal iagnosis Code Pneumonia iagnosis: E/irect Admit Risk Adjustment: No ata 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 opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other IC-9-CM diagnosis and procedure codes, which require retrospective data entry. ata Accuracy: Variation may exist in the assignment of IC-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. To be part of the measure population, a patient must have received an antibiotic either during the hospitalization or within 24 hours prior to hospital arrival plus during the hospitalization. Measure specifications do not require documentation of the exact date and time of the antibiotic taken prior to hospitalization. To be part of the measure population, a patient must be an Emergency epartment patient and have a blood culture collected prior to an admission order. -3
Measure Analysis Suggestions: None Sampling: Yes, please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section. ata Reported As: Aggregate rate generated from count data reported as a proportion Selected References: Heffelfinger J, owell SF, Jorgensen JH, Klugman KP, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the rug-resistant Streptococcus Pneumoniae Therapeutic Working Group. Archives of Internal Medicine. 2000, 160:1399-1408. King M, Whitney CG, Parekh F, Farley MM. Recurrent invasive pneumococcal disease: a population-based assessment. Clin Infect is 2003; 37:1029-36. 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 isease Society and the Canadian Thoracic Society. Clin Infect is 2000;31:383-421. Mandell LA, Wunderink RG, Anzueta A, artlett JG, Infectious iseases Society of America; American Thoracic Society. Infectious iseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect is. 2007 March 1;44 Suppl 2:S27-72. Metersky ML, Ma A, ratzler W, et al. Predicting bacteremia in patients with community-acquired pneumonia. Am J Respir Crit Care Med 2004; 169: 342-347. van der Eerden MM, Vlaspolder F, de Graaf CS, Groot T, ronsveld W, Jansen HM. Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study. Thorax 2005; 60:672-8. -4
: lood Cultures Performed in the Emergency epartment Prior to Initial Antibiotic Received in Hospital Numerator: Number of pneumonia patients whose initial E blood culture was performed prior to the administration of the first hospital dose of antibiotics. enominator: Pneumonia patients 18 years of age and older who have initial blood culture collected in the E. START Run cases that are included in the PN Initial Patient Population and pass the edits defined in the Transmission ata Processing Flow: Clinical through this measure. Variable Key: Antibiotic Timing lood Culture Timing lood Culture Collection ay uration of Stay Initial Antibiotic ate Initial Antibiotic Time Chest -Ray = 2, 3 = 1 Comfort Measures Only = 1 = 2, 3, 4 Clinical Trial = Y = N H -5
H Pneumonia iagnosis: E/ irect Admit = 2 = 1, 3 Pneumonia iagnosis: E/ irect Admit = 3 = 1 Antibiotic Received = 1 or 4 = 2 or 3 lood Culture Collected = 2,3,4 = 1 Arrival ate = UT Non-UT Value uration of Stay = ischarge ate Arrival ate (in days) uration of Stay 1 ischarge isposition = 4, 6, 7 >1 = 1, 2, 3, 5, 8 Arrival Time =UT Non-UT Value I -6
I Antibiotic Grid Not Populated Antibiotic Name Note: The front-end edits reject cases containing invalid data and/or an incomplete Antibiotic Grid. A complete Antibiotic Grid requires all data elements in the row to contain either a valid value and/or UT. On table 2.1 Note: Proceed only with Antibiotics that have an associated non-ut Antibiotic Administration ate Antibiotic Administration ate =UT for all antibiotic doses Non-UT Value for at least one antibiotic dose Initial Antibiotic ate = The Antibiotic Administration ate that corresponds to the initial antibiotic dose. Note: The initial antibiotic dose is the earliest antibiotic dose administered that is on Table 2.1. - If there is more than one antibiotic on the earliest date, select the one having the earliest non-ut Antibiotic Administration Time. - If there is only one antibiotic on the earliest date retain that earliest antibiotic as the Initial Antibiotic ose. Initial lood Culture Collection ate =UT Non-UT Value lood Culture Collection ay (in days) = Initial Antibiotic ate minus Initial lood Culture Collection ate < 0 days lood Culture Collection ay > 0 days E = 0 day Antibiotic Administration Time =UT for the antibiotic considered the Initial Antibiotic ate Non-UT time for the antibiotic considered the Initial Antibiotic ate J -7
J Initial Antibiotic Time = The Antibiotic Administration Time that corresponds to the initial antibiotic dose. Initial lood Culture Collection Time =UT Non-UT Value Antibiotic Timing = Initial Antibiotic ate and Initial Antibiotic Time minus Arrival ate and Arrival Time (in minutes) Will e Rejected Case < 0 minutes Antibiotic Timing 0 minutes Z lood Culture Timing = Initial Antibiotic ate and Initial Antibiotic Time minus Initial lood Culture Collection ate and Initial lood Culture Collection Time (in minutes) lood Culture Timing In Measure < 0 minutes Population Not In Measure Population E 0 minutes E In Numerator Population Z STOP -8
Pneumonia (PN) - 3b: lood Cultures Performed in the Emergency epartment Prior to Initial Antibiotic Received in Hospital Numerator: enominator: Variable Key: Number of pneumonia patients whose initial Emergency epartment (E) blood culture was performed prior to the administration of the first hospital dose of antibiotics. Pneumonia patients 18 years of age and older who have initial blood culture collected in the E. Antibiotic Timing, lood Culture Timing, lood Culture Collection ay, uration of Stay, Initial Antibiotic ate, and Initial Antibiotic Time. 1. Start Run cases that are included in the Pneumonia (PN) Initial Patient Population and pass the edits defined in the Transmission ata Processing Flow: Clinical through this measure. 2. Check Chest -Ray a. If Chest -Ray is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If Chest -Ray equals 2 or 3, the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop c. If Chest -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 and will be rejected. Stop b. If Comfort Measures Only equals 1, the case will proceed to a Measure Category Assignment of 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 and will be rejected. Stop b. If Clinical Trial equals Yes, the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop c. If Clinical Trial equals No, continue processing and proceed to Pneumonia iagnosis: E/irect Admit. -9
5. Check Pneumonia iagnosis: E/irect Admit a. If Pneumonia iagnosis: E/irect Admit is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If Pneumonia iagnosis: E/irect Admit equals 2, the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop c. If Pneumonia iagnosis: E/irect Admit equals 3, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop d. If Pneumonia iagnosis: E/irect Admit equals 1, continue processing and proceed to Antibiotic Received. 6. Check Antibiotic Received a. If Antibiotic Received is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If Antibiotic Received equals 1 or 4, the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop c. If Antibiotic Received equals 2 or 3, continue processing and proceed to lood Culture Collected. 7. Check lood Culture Collected a. If lood Culture Collected is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If lood Culture Collected equals 2, 3, or 4, the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop c. If lood Culture Collected equals 1, continue processing and proceed to Arrival ate. 8. Check Arrival ate a. If the Arrival ate is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If the Arrival ate equals Unable to etermine, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop c. If the Arrival ate equals a Non Unable to etermine Value, continue processing and proceed to the uration of Stay calculation. 9. Calculate uration of Stay. uration of Stay, in days, is equal to the ischarge ate minus the Arrival ate. 10. Check uration of Stay -10
a. If the uration of Stay is greater than 1, continue processing and proceed to step 12 to check Arrival Time. o not check ischarge isposition. b. If the uration of Stay is less than or equal to 1, continue processing and proceed to ischarge isposition. 11. Check ischarge isposition only if uration of Stay was less than or equal to 1 a. If the ischarge isposition equals 4, 6, or 7 the case will proceed to a Measure Category Assignment of and will not be in the Measure Population. Stop b. If ischarge isposition equals 1, 2, 3, 5, or 8, continue processing and proceed to Arrival Time. 12. Check Arrival Time a. If the Arrival Time is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If the Arrival Time equals Unable to etermine, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop c. If the Arrival Time equals a Non Unable to etermine Value, continue processing and proceed to Antibiotic Name. 13. Check Antibiotic Name a. If the Antibiotic Name is on Table 2.1, continue processing and proceed to Antibiotic Administration ate. b. If the Antibiotic Grid is not populated, the case will proceed to a Measure Category Assignment of and will be rejected. Stop Note: The front-end edits reject cases containing invalid data and/or an incomplete Antibiotic Grid. A complete Antibiotic Grid requires all data elements in the row to contain either a valid value and/or Unable to etermine. 14. Check Antibiotic Administration ate a. If the Antibiotic Administration ate equals Unable to etermine for all antibiotic doses, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop b. If the Antibiotic Administration ate equals a Non Unable to etermine Value for at least one antibiotic dose, continue processing and proceed to the Initial Antibiotic ate determination. Note: Proceed only with Antibiotics that have an associated Non Unable to etermine Antibiotic Administration ate. 15. etermine the Initial Antibiotic ate. The Initial Antibiotic ate equals the Antibiotic Administration ate that corresponds to the initial antibiotic dose. -11
Note: The initial antibiotic dose is the earliest antibiotic dose administered that is on Table 2.1. If there is more than one antibiotic on the earliest date, select the one having the earliest non Unable to etermine Antibiotic Administration Time. If there is only one antibiotic on the earliest date, retain that earliest antibiotic as the Initial Antibiotic ose. 16. Check Initial lood Culture Collection ate a. If the Initial lood Culture Collection ate is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If the Initial lood Culture Collection ate equals Unable to etermine, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop c. If the Initial lood Culture Collection ate equals a Non Unable to etermine Value, continue processing and proceed to the lood Culture Collection ay calculation. 17. Calculate lood Culture Collection ay. lood Culture Collection ay, in days, is equal to the Initial Antibiotic ate minus the Initial lood Culture Collection ate. 18. Check lood Culture Collection ay a. If the lood Culture Collection ay is less than zero days, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop b. If the lood Culture Collection ay is greater than zero days, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop c. If the lood Culture Collection ay is equal to zero days, continue processing and proceed to Antibiotic Administration Time. 19. Check Antibiotic Administration Time a. If the Antibiotic Administration Time is equal to Unable to etermine for the antibiotic that is considered the Initial Antibiotic ate, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. b. If the Antibiotic Administration Time is a Non Unable to etermine time for the antibiotic that is considered the Initial Antibiotic ate, continue processing and proceed to determine the Initial Antibiotic Time. 20. etermine the Initial Antibiotic Time. The Initial Antibiotic Time is equal to the Antibiotic Administration Time that corresponds to the Initial Antibiotic ose. 21. Check Initial lood Culture Collection Time -12
a. If the Initial lood Culture Collection Time is missing, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If the Initial lood Culture Collection Time equals Unable to etermine, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop c. If the Initial lood Culture Collection Time equals a Non Unable to etermine Value, continue processing and proceed to the Antibiotic Timing calculation. 22. Calculate Antibiotic Timing. Antibiotic Timing, in minutes, is equal to the Initial Antibiotic ate and Initial Antibiotic Time minus the Arrival ate and Arrival Time. 23. Check Antibiotic Timing a. If the Antibiotic Timing is less than zero minutes, the case will proceed to a Measure Category Assignment of and will be rejected. Stop b. If the Antibiotic Timing is greater than or equal to zero minutes, continue processing and proceed to the lood Culture Timing calculation. 24. Calculate lood Culture Timing. lood Culture Timing, in minutes, is equal to the Initial Antibiotic ate and Initial Antibiotic Time minus the Initial lood Culture Collection ate and initial lood Culture Collection Time. 25. Check lood Culture Timing a. If the lood Culture Timing is less than zero minutes, the case will proceed to a Measure Category Assignment of and will be in the Measure Population. Stop b. If the lood Culture Timing is greater than or equal to zero minutes, the case will proceed to a Measure Category Assignment of E and will be in the Numerator Population. Stop -13