PRIME Project 3.1 Antibiotic Stewardship



Document Control LogVersionDateDetailsV1.02/29/16Metric specifications not arranged by ProjectMetric specifications in native format without editingV2.03/7/16Metrics arranged by ProjectMetric specifications edited for PRIMEV2.14/29/16Added PRIME Eligible Population for DMPHsAdded sentence requiring inclusion of individuals who meet either Population #1 or #2 criteria. Modified continuous enrollment language for PRIME Eligible Population #2 to be 12 months during the Measurement PeriodReplaced “Appendix 2” with “Table 5” in GPP footnoteCorrected 3.1.4 Prophylactics measure denominator to be Project 3.1 Target Population instead of PRIME Eligible PopulationClarified for 3.1.3 NHSN Antimicrobial Use that the Antibiotic Resistance option is not a part of PRIME Modified Exclusions for 3.1.4Added Exclusion to denominator for 3.1.1 NQF 0058V2.25/31/16Approved by DHCS Added exclusion of inpatient encounters in PRIME Eligible Population #1Added PRIME Eligible Population Tenure and Exclusion criteriaNarrowed metric 3.1.3 to the use of anti-MRSA drugs, carbapenems, anti- pseudomonal penicillins and cephalosporins.Added Individual Measure Flow Diagram to NQF 0058Revised Hospital Acquired C. Diff Infections metric specification and Summary Table description Metric Questions or Feedback: A link to a form is provided. Please complete one form for each request for clarification per metric. You may submit additional requests as needed.Measurement PeriodsDemonstration Year Mid-Year Report Measurement PeriodFinal Year-End Report Measurement PeriodDY 11Not applicableJul 1, 2015 – Jun 30, 2016DY12Jan 1, 2016 – Dec 31, 2016Jul 1, 2016 – Jun 30, 2017DY13Jan 1, 2017 – Dec 31, 2017Jul 1, 2017 – Jun 30, 2018DY14Jan 1, 2018 – Dec 31, 2018Jul 1, 2018 – Jun 30, 2019DY15Jan 1, 2019 – Dec 31, 2019Jul 1, 2019 – Jun 30, 2020Note: Specifications for PRIME measures that are CMS Core measures refer to CMS value sets PRIME Eligible Population for Designated Public Hospitals (DPHs) only:The PRIME Eligible Population includes the combination of both Population #1 and Population #2. An individual does not have to meet criteria of both Population #1 and Population #2. Any individual who meets either PRIME Eligible Population #1 criteria or PRIME Eligible Population #2 criteria must be included in the PRIME Eligible Population.Population #1: Individuals of all ages with at least 2 encounters with the PRIME Entity Primary Care team during the measurement period. A Primary Care team encounter is counted if occurred with a member of the Primary Care Team from Family Medicine, Internal Medicine, or Pediatrics. The PRIME Entity may choose to include populations who are seen for primary care in a specialty clinic (e.g. HIV) Encounters include either a face-to-face visit with a primary care provider OR any encounter included in the list of eligible non-traditional service types described in the Global Payment Program (for PRIME, encounters not limited to uninsured individuals.)Only encounters with the Primary Care team in the ambulatory setting will be counted toward the above 2 encounter requirement. Encounters with primary care team members in the inpatient setting do not count toward the two primary care encounter requirement. [This does not impact the expansion of the PRIME Eligible Population to include inpatient or acute care utilization as specified by the Project Target Population criteria e.g. in Domain 3]Population #2Individuals of all ages who are in Medi-Cal Managed Care with 12 months of continuous assignment to the PRIME Entity during the Measurement Period.No more than one gap in enrollment or assignment with the PRIME Entity of up to 45 days during the Measurement Period.Individual must be enrolled in the primary plan and assigned to the PRIME Entity on the final day of the Measurement Period.PRIME Eligible Population for District Municipal Hospitals (DMPHs) only:The PRIME Eligible Population is all individuals with at least two encounters by the participating PRIME entity among Medi-Cal Beneficiaries. Tenure Criteria for DPH/DMPH PRIME Eligible Population Encountered LivesThe first of the two required primary care encounters (DPH) or Medi-Cal encounters (DMPH) must occur during the first 6 months of the measurement periodThe second required (primary care) encounter may occur at any point during the measurement period.The two (primary care) encounters during the measurement period fulfilling the PRIME Eligible Population eligibility criteria cannot occur on the same day.Exclusion Criteria for DPH/DMPH PRIME Eligible PopulationExclusion for patients no longer the responsibility of the PRIME Entity at the end of the measurement period:Any patient meeting the PRIME Eligible Population Encountered Lives criteria in a given measurement period who then experiences any of the following scenarios, will be removed from the PRIME Eligible Population for that measurement period, when the PRIME entity has documentation that before the end of the measurement period:The patient has died.The patient has changed their care to a PCP in a health system that is not the PRIME Entity.The patient has been incarcerated.Project 3.1 Target Population is as follows: For NQF 0058, the target population is the PRIME Eligible PopulationFor all others, refer to the metric denominator Summary Table3.1.1 - NQF 0058: Avoidance of Antibiotic Treatment in Adults with Acute BronchitisSpecification Source: 2016 PQRS Individual Claims Registry Measure Specification Supporting DocumentsNumerator: Patients who were dispensed antibiotic medication on or three days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e. 1-numerator/denominator) to reflect the number of people that were not dispensed an antibiotic.Denominator: All patients aged 18 through 64 years of age in the PRIME target population with an outpatient or emergency department (ED) visit with a diagnosis of acute bronchitis during the measurement period3.1.2 - Avoidance of Antibiotic Treatment with Low Colony Urinary CulturesSpecification Source: PRIME Innovative Measure StewardNumerator: Number of new systemic antibiotics administered for the denominator urine cultures within 2 calendar days before or after a collected urine culture and that are continued more than 2 calendar days after the urine result is finalizedDenominator: Number of urine cultures collected in adult PRIME entity inpatients where colony counts for each identified pathogen (bacteria or fungi) are <50,000, regardless of catheter presence, AND there is no other positive (bacteria or fungi) microbiology culture at another site within 2 calendar days before or after the collection of the urine culture.3.1.4 - Prophylactic antibiotics discontinued at time of surgical closureSpecification Source: PRIME Innovative Measure StewardNumerator: Number of surgical cases in the denominator in which peri-operative prophylactic antibiotics are not administered after surgical closureDenominator: Number of NHSN-defined clean surgical cases in individuals from the PRIME entity eligible population aged 18 years or older at the beginning of the measurement period who have had non-cardiothoracic surgeries.3.1.3 - NQF 2720: National Healthcare Safety Network Antimicrobial Use Measure (Variation)Specification Source: CDC Antimicrobial Use ModuleNumerator: The aggregate sum of days for which any amount of a specific antimicrobial agent was administered to individual patients as documented in the eMAR and/or BCMA. (Variation: For PRIME, metric is limited to anti-MRSA drugs, carbapenems, anti-pseudomonal penicillins and cephalosporins)Denominator: Days Present: time period during which a given patient is at risk for antimicrobial exposure for a given patient location (Inpatient, Facility-wide, excluding oncology and BMT units and services)3.1.5 - Reduction in Hospital Acquired Clostridium Difficile InfectionsSpecification Source: CDC National Healthcare Safety Network (NHSN)Numerator: Total number of observed hospital-onset CDI LabID events among all inpatients in the facility, excluding well baby-nurseries and NICUsDenominator: Total number of expected hospital-onset CDI LabID events, calculated using the facility?s number of inpatient days, bedsize, affiliation with medical school, microbiological test used to identify C. difficile, and community-onset CDI admission prevalence rate.3.1.1 - NQF 0058: Avoidance of Antibiotic Treatment in Adults with Acute BronchitisDESCRIPTION:Percentage of adults 18 through 64 years of age in the PRIME target population with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episodeINSTRUCTIONS:This measure is to be reported at each occurrence of acute bronchitis during the reporting period. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.Measure Reporting via Registry:ICD-10-CM diagnosis codes, CPT or HCPCS codes, and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to report the numerator of the measure.The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.DENOMINATOR:All patients aged 18 through 64 years of age in the PRIME Eligible Population with an outpatient or emergency department (ED) visit with a diagnosis of acute bronchitis during the measurement periodDENOMINATOR NOTE: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the acute bronchitis diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion.Denominator Criteria (Eligible Cases):Patients 18 through 64 years of age on date of encounterANDDiagnosis for acute bronchitis (ICD-10-CM): J20.3, J20.4, J20.5, J20.6, J20.7, J20.8, J20.9ANDPatient encounter during the reporting period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205,99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439NUMERATOR:Patients in the PRIME target population who were not prescribed or dispensed antibiotics on or within 3 days of the initial date of serviceNumerator Instructions: For performance, the measure will be calculated as the number of patient encounters where antibiotics were neither prescribed nor dispensed on or within 3 days of the episode for acute bronchitis over the total number of encounters in the denominator (patients aged 18 through 64 years with an outpatient or ED visit for acute bronchitis). A higher score indicates appropriate treatment of patients with acute bronchitis (e.g., the proportion for whom antibiotics were not prescribed or dispensed on or three days after the encounter).Antibiotic MedicationsDescriptionPrescriptionAminoglycosides?Amikacin?Kanamycin?Tobramycin?Gentamicin?StreptomycinAminopenicillins?Amoxicillin?AmpicillinAntipseudomonal penicillins?PiperacillinBeta-lactamase inhibitors?Amoxicillin-?Piperacillin-?Ticarcillin-clavulanate clavulanatetazobactam?Ampicillin- sulbactamFirst-generation cephalosporins?Cefadroxil?Cefazolin?CephalexinFourth-generationcephalosporins?CefepimeKetolides?TelithromycinLincomycin derivatives?Clindamycin?LincomycinMacrolides?Azithromycin?Erythromycin?Erythromycin?Clarithromycin?Erythromycinlactobionate ethylsuccinate?Erythromycin stearateMiscellaneous antibiotics?Aztreonam?Daptomycin?Metronidazole?Chloramphenicol?Erythromycin-?Vancomycin?Dalfopristin-sulfisoxazole quinupristin?LinezolidNatural penicillins?Penicillin G?Penicillin G?Penicillin V potassium benzathine-procaine?Penicillin Gprocaine?Penicillin Gbenzathine?Penicillin Gsodium potassiumPenicillinase resistant penicillins?Dicloxacillin?Nafcillin?OxacillinQuinolones?Ciprofloxacin?Levofloxacin?Norfloxacin?Gemifloxacin?Moxifloxacin?OfloxacinRifamycin derivatives?RifampinSecond generationcephalosporin?Cefaclor?Cefoxitin?Cefuroxime?Cefotetan?CefprozilSulfonamides?Sulfadiazine?Sulfamethoxazol e-trimethoprimTetracyclines?Doxycycline?Minocycline?TetracyclineThird generation cephalosporins?Cefdinir?Cefotaxime?Ceftibuten?Cefditoren?Cefpodoxime?Ceftriaxone?Cefixime?CeftazidimeDescriptionPrescriptionUrinary anti-infectives?Fosfomycin??????????Nitrofurantoin?Nitrofurantoin macrocrystals? Nitrofuantoin macrocrystals- monohydrate? TrimethoprimNumerator Options:Performance Met:Antibiotic neither prescribed nor dispensed (4124F) ORMedical Performance Exclusion:Documentation of medical reason(s) for prescribing or dispensing antibiotic (eg, intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis/ mastoiditis/bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections/venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis/UTI, acne, HIV disease/asymptomatic HIV, cystic fibrosis, disorders of the immune system, malignancy neoplasms, chronic bronchitis, emphysema, bronchiectasis, extrinsic allergic alveolitis, chronic airway obstruction, chronic obstructive asthma, pneumoconiosis and other lung disease due to external agents, other diseases of the respiratory system, and tuberculosis) (4120F with 1P)ORPerformance Not Met:Antibiotic prescribed or dispensed (4120F)CLINICAL RECOMMENDATION STATEMENTS:Clinical guidelines do not support antibiotic treatment of otherwise healthy adults with acute bronchitis due to the viral origin of acute bronchitis. Patients with chronic bronchitis, COPD or other chronic comorbidity may be treated with antibiotics and are therefore excluded from the measure denominator. (Gonzales R., D.C. Malone, J.H. Maselli, et al, 2001)2016 Registry Individual Measure FlowPQRS #116 NQF #0058: Avoidance of Antibiotic Treatment for Adults with Acute BronchitisPlease refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure.Start with DenominatorCheck Patient Age:If Age equal to 18 thru 64 years of age on Date of Service equals No during the measurement period, do not include in Eligible Patient Population. Stop Processing.If Age equal to 18 thru 64 years of age on Date of Service equals Yes during the measurement period, proceed to check Patient Diagnosis.Check Patient Diagnosis:If Diagnosis of Acute Bronchitis as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.If Diagnosis of Acute Bronchitis as Listed in the Denominator equals Yes, proceed to check Encounter Performed.Check Encounter Performed:If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing.If Encounter as Listed in the Denominator equals Yes, include in the Eligible population.Denominator Population:Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 episodes in the sample calculation.Start NumeratorCheck Antibiotic Neither Prescribed Nor Dispensed:If Antibiotic Neither Prescribed Nor Dispensed equals Yes, include in Reporting Met and Performance Met.Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 episodes in Sample Calculation.If Antibiotic Neither Prescribed Nor Dispensed equals No, proceed to Documentation of Medical Reason(s) for Prescribing or Dispensing Antibiotic.Check Documentation of Medical Reason(s) for Prescribing or Dispensing Antibiotic:If Documentation of Medical Reason(s) for Prescribing or Dispensing Antibiotic equals Yes, include in Reporting Met and Performance Exclusion.Reporting Met and Performance Exclusion letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter b equals 1 episode in the Sample Calculation.If Documentation of Medical Reason(s) for Prescribing or Dispensing Antibiotic equals No, proceed to Antibiotic Prescribed or Dispensed.Check Antibiotic Prescribed or Dispensed:If Antibiotic Prescribed or Dispensed equals Yes, include in the Reporting Met and Performance Not Met.Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 episodes in the Sample Calculation.If Antibiotic Prescribed or Dispensed equals No, proceed to Reporting Not Met.Check Reporting Not Met:If Reporting Not Met equals No, Quality Data Code or equivalent not3.1.2 - Avoidance of Antibiotic Treatment for Asymptomatic Urinary Colonization I. BACKGROUNDMeasure TitleAvoidance of Antibiotic Treatment for Low Colony Count Urinary CulturesMeasure DescriptionHospitalized individuals will not be unnecessarily treated with antibiotics for urine cultures that do not show bacterial levels consistent with infection.Project(s)3.1 Resource Utilization: Antibiotic StewardshipMeasure Steward Entity(/ies), OrganizationUCD, UCI, UCSDII. REPORTINGMeasure NumeratorNumber of new systemic antibiotics administered for the denominator urine cultures within 2 calendar days before or after a collected urine culture and that are continued more than 2 calendar days after the urine result is finalizedNumerator Code/s (CPT, ICD10, other) Tracking of “new systemic antibiotics” as per local health system approaches (e.g., medication lists, order sets, pharmacy information systems)Measure DenominatorNumber of urine cultures collected in adult PRIME entity inpatients where colony counts for each identified pathogen (bacteria or fungi) are <50,000, regardless of catheter presence, AND there is no other positive (bacteria or fungi) microbiology culture at another site within 2 calendar days before or after the collection of the urine culture.Denominator Code/s (CPT, ICD10, other)CPT:Urine Culture: 87086 or 87088Culture, Aerobic and Anaerobic: 87070,87075,87205LOINC:395: Culture, Urine, Routine630R: Culture, Urine, Routine630-4: Culture, Urine, Routine, Bacteria identified1454: Urine Culture, Colony Count: Sensitivity on any Flora5529: Urine Culture and Urinalysis634-6: Bacteria identified in Unspecified specimen by Aerobe culture635-3: Bacteria identified in Unspecified specimen by Anaerobe cultureExclusion/sCultures ordered from ICU, oncology/BMT units and services Reporting Business Logic Initial Population =AND: Target Project PopulationAND: Inpatient Admission at: “Measurement Period”AND: Age >= 18 year(s) at: "Inpatient Admission"Denominator =AND: Initial PopulationAND: Urine Culture satisfies allCollection date <2 calendar days before start of admission dateCollection date before end of discharge dateResult <50,000 Colony counts for each identified organismAND: Microbiology culture at another site satisfies all<2 days before start of urine culture collection date<2 days after start of urine culture collection dateResult = not positive (bacteria or fungi)Denominator Exclusions =Urine culture collection hospital site origin =OR: Union of:ICUsOncology units and servicesBone Marrow Transplant units and servicesNumerator =Systemic antibiotics satisfies allStart date <2 calendar days before denominator urine culture collection dateStart date <2 calendar days after denominator urine culture collection dateAND: continued >2 calendar days after date of denominator urine culture result reported as FinalNumerator Exclusions =NoneDenominator Exceptions =NoneStratifications =NoneDefinitions as applicableN/AOther Notes as applicablePRIME Entity performance to be benchmarked against entities own baseline determined in initial 3 yearsMeasurement Period as applicableDY 11: Final End of Year: July 1, 2015 through June 30, 2016 DY 12-DY 15:Interim Mid-Year: January 1, 20xx through December 31, 20xxFinal End of Year: July 1, 20xx through June 30, 20xxIII. RATIONALERationale for MeasureScientific Acceptability3.1.4 - Prophylactic antibiotics discontinued at time of surgical closure I. BACKGROUNDMeasure TitleProphylactic antibiotics discontinued at time of surgical closure (variation on NQF 0529)Measure DescriptionSurgical patients whose prophylactic antibiotics were discontinued at the time of surgical closure. The Centers for Disease Control and Prevention have put forth the following category 1A recommendation: “In clean and clean‐contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain.”Project(s)3.1 Antibiotic StewardshipMeasure Steward Entity(/ies), OrganizationUniversity of California at Davis, University of California Irvine, University of California Los Angeles and University of California San DiegoII. REPORTINGMeasure NumeratorNumber of surgical cases in the denominator in which peri-operative prophylactic antibiotics are not administered after surgical closureNumerator Code/s (CPT, ICD10, other)Surgery DateSurgery End Time (see Appendix for The Joint Commission Specifications)Antibiotic Administration DateAntibiotic Administration TimeMeasure DenominatorNumber of NHSN-defined clean surgical cases in individuals aged 18 years or older at the beginning of the measurement period who have had non-cardiothoracic surgeries.Denominator Code/s (CPT, ICD10, other)NHSN-defined clean surgical cases:Admission DateAnesthesia Start DateAntibiotic Administration RouteAntibiotic NameAntibiotic ReceivedBirthdateClinical TrialDischarge Date ICD-10-CM Principal Diagnosis CodeICD-10-CM Principal Procedure CodeInfection Prior to AnesthesiaOral AntibioticsOther SurgeriesPerioperative DeathReasons to Extend AntibioticsSurgical Incision DateSurgical Incision TimeExclusion/sChildren < 18 (this we have since we specify adults)non-clean casescardiothoracic surgeries (CARD, CBGB, CBGC, THOR)antibiotics not used for peri-operative prophylaxis (e.g. for treatment)surgeries with concomitant non-clean proceduresDefinitions as applicableOther Notes as applicableLink to NQF 0529Measurement Period as applicableDY 11:Final End of Year: July 1, 2015 through June 30, 2016DY 12-15Interim Mid-Year: January 1, 20xx through December 31, 20xxFinal End of Year: July 1, 20xx through June 30, 20xxIII. RATIONALERationale for MeasureScientific AcceptabilityIV. AppendixFrom: Specifications Manual for Joint Commission National Quality Core Measures (2010A1)Data Element Name:Surgery End TimeDefinition:The surgical end time of the principal procedure.Suggested Data Collection Question:What was the surgical end time of the principal procedure?Format:Length:5 - HH:MM (with or without colon) or UTDType:TimeOccurs:1Allowable Values:HH = Hour (00-23) MM = Minutes (00-59) UTD = Unable to DetermineTime must be recorded in military time format. With the exception of Midnight and Noon:If the time is in the a.m., conversion is not requiredIf the time is in the p.m., add 12 to the clock time hourExamples: Midnight = 00:00 Noon = 12:00 5:31 am = 05:31 5:31 pm = 17:31 11:59 am = 11:59 11:59 pm = 23:59Note: 00:00 = midnight. If your electronic system documents time as 00:00 11-24-2007, review supporting documentation to determine if the Surgery End Date should remain 11-24-2007 or if it should be converted to 11-25-2007. When converting 24:00 to 00:00 do not forget to change the Surgery End Date.Example: Midnight or 24:00 on 11-24-2007 = 00:00 on 11-25-2007Notes for Abstraction:For times that include “seconds,” remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00If the principal procedure end time is unable to be determined from medical record documentation, enter UTD.The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time/format or outside of the parameters of care for this data element [Surgery End Date/Surgery End Time cannot be before Surgery Start Date/Surgical Incision Time]) and no other documentation is found that provides this information, the abstractor should select “UTD.” Examples:Documentation indicates the Surgery End Time was 3300. No other documentation in the medical record provides a valid time. Since the Surgery End Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”Documentation indicates the Surgery End Date was 3-11-2008, Surgery End Time was 1100, Surgery Start Date was 3-11-2008 and Surgical Incision Time was 2100. Documentation in the medical record support the Surgery Start Date and the Surgical Incision Time as being accurate. No other documentation in the medical record provides an accurate Surgery End Time. Since Surgery End Date/Surgery End Time are before the Surgery Start Date/Surgical Incision Time, it is outside of the paramenter of care for this data element and the abstractor should select “UTD.” Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Surgery End Time allows the case to be accepted into the warehouse.If multiple procedures occur during the same surgical episode, the Surgical Incision Time captured will be the incision that occurs first and the Surgery End Time will be the end time that occurs last.If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Surgery End Time of the initial procedure. Do NOT use the date/time the patient returns to the OR for closure.Follow the priority order within the Inclusion List of this data element’s Guidelines for Abstraction:First, review all sources for any of the first priority synonyms for Surgery End Time. If multiple times are found, select the earliest time among the first priority synonyms.Next, if none of the first priority synonyms are documented, go to the second priority list of synonyms for Surgery End Time. If multiple times are found, select the earliest time among the second priority list of synonyms.Finally, if none of the first and second priority synonyms are documented, go to the third priority list of synonyms for Surgery End Time. If multiple times are found, select the earliest time among the third priority list of synonyms. Note: Priority order applies to items in inclusion table, not to source document. Also, please note the synonyms in the lists are alphabetized, not prioritized.Suggested Data Sources:Anesthesia recordCirculation recordOperative reportAdditional Notes:Guidelines for Abstraction:InclusionFollow the priority order below. If multiple times are found, use earliest time among the highest priority.First priority:Close timeEOS/end of surgeryEnd timeProcedure end timeProcedure stop timeStop timeTime incision closedSecond priority:Discharge to PACU/recovery roomOperating room end, finish, or stop timeRoom out timeTime patient taken from surgeryTo PACU/recovery roomThird priority:Anesthesia end timeAnesthesia stop timeArrival in the PACU/recovery roomExclusionsNone3.1.3 - NQF 2720: National Healthcare Safety Network Antimicrobial Use Measure (Variation)Purpose:The goal of this National Healthcare Safety Network (NHSN) AU Module is to provide a mechanism for facilities to report and analyze antimicrobial use as part of local or regional efforts to reduce antimicrobial resistant infections through antimicrobial stewardship efforts.6 It is based off of the National Healthcare Safety Network (NHSN) Antibiotic Use and Resistance Module but is modified to allow facilities that currently are unable to report all antibiotic use to NHSN to allow for antibiotic use analysis within a PRIME entity. For the purpose of PRIME, the intent is to limit the use of anti-MRSA drugs, carbapenems, anti-pseudomonal penicillins and cephalosporins.Antimicrobial Use (AU) OptionIntroduction: Rates of resistance to antimicrobial agents continue to increase at hospitals in the United States.1 The two main reasons for this increase are patient-to-patient transmission of resistant organisms and selection of resistant organisms because of antimicrobial exposure.2 Previous studies have shown that feedback of reliable reports of rates of antimicrobial use and resistance to clinicians can improve the appropriateness of antimicrobial usage.3-5Objectives: The primary objective of the Antimicrobial Use option is to evaluate trends of specific antimicrobial usage over time at the facility levels.Methodology: The primary antimicrobial usage metric reported to this module is antimicrobial days per 1000 days present. An antimicrobial day (also known as day of therapy) is defined by any amount of a specific antimicrobial agent administered in a calendar day to a particular patient as documented in the electronic medication administration record (eMAR) and/or bar coding medication record (BCMA).Settings: NHSN-defined inpatient locations locations to include medical, surgical, and medical/surgical ICUs and non-ICUs, excluding oncology and BMT units and services. Numerator Data (Antimicrobial Days): Antimicrobial Days (Days of Therapy): Defined as the aggregate sum of days for which any amount of a specific antimicrobial agent was administered to individual patients as documented in the eMAR and/or BCMA.8-11 Appendix B provides the full list of antimicrobial agents included in this metric. Aggregate antimicrobial days are reported monthly for inpatient locations.Denominator Data (Days Present): The numerator will be analyzed against the denominators of days present for facility-wide inpatient only. The denominator is further defined below.Days present: Defined as time period during which a given patient is at risk for exposure a given patient location. For facility-wide inpatient analyses, days present is calculated as the number of patients (excluding oncology and BMT patients and services) who were present for any portion of each day of a calendar month at the facility-wide inpatient location. The aggregate measure is calculated by summing up all of the days present for facility-wide inpatient for a given month.Table. Location-specific and Facility-wide Inpatient MetricsMetric CollectedMetric DefinitionCommentsFacility-wide Inpatient AnalysesAntimicrobial Days/Days presentDrug-specific antimicrobial days for a facility per month/Days present per facility-wide inpatient per monthOne patient can contribute only one day present per calendar day for a facility. Thus, one denominator is obtained for an entire facility. The day present measure for facility-wide inpatient may be lower when compared to sum total from location-specific comparison.Data Analyses:Antimicrobial use data are expressed as incidence density rates of antimicrobial days per days present stratified by patient care location and facility-wide inpatient. Antimicrobials will be grouped during analysis by spectrum of activity.ReferencesHidron AI, Edwards JR, Patel J, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006- 2007. Infect Control Hosp Epidemiol 2008;29:996-1011.Schwartz MN. Use of antimicrobial agents and drug resistance. N Eng J Med 1997;337:491-2.Ansari F, Gray K, Nathwani D, et al. Outcomes of an intervention to improve hospital antibiotic prescribing; interrupted time series with segmented regression analysis. J Antimicrob Chemother 2003;52:842-8.Solomon DH, Van Houten L, Glynn RJ. Academic detailing to improve use of broad- spectrum antibiotics at an academic medical center. Arch Inter Med 2001;161:1897-902.Fraser GL, Stogsdill P, Dickens JD Jr, et al. Antibiotic optimizations: an evaluation of patient safety and economic outcomes. Arch Inter Med 1997;157-1689-94.Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis 2007;44:159-77.National Healthcare Safety Network (NHSN) Patient Safety Component: Clinical Document Architecture. DN, Evans RS, Camins B, et al. Deriving measures of intensive care unit antimicrobial use from computerized pharmacy data: methods, validation, and overcoming barriers. Infect Control Hosp Epidemiol 2011;32:472-80.Polk RE, Fox C, Mahoney A, Letcavage J, MacDougall C. Measurement of adult Antibacterial Drug Use in 130 US Hospitals: Comparison of Defined Daily Dose and Days of Therapy. Clin Infect Dis 2007;44:664-70.Kuster SP, Ledergerber B, Hintermann A, et al. Quantitative antibiotic use in hospitals: comparison of measurements, literature review, and recommendations for standards of reporting. Infection 2008; 6:549-59.Berrington A. Antimicrobial prescribing in hospitals: be careful what you measure. J Antimicrob Chemother 2010:65:163-168.Appendix A. Table of Instructions: Antimicrobial UseData FieldInstructions for CDA of Antimicrobial Use DataMonthRequired. Record the 2-digit month during which the data were collected for this location.YearRequired. Record the 4-digit year during which the data were collected for this location.Numerator:Antimicrobial days per month per locationRequired.Antimicrobial days are defined as the aggregate sum of the days of exposure for which a specific antimicrobial was administered. These are required to be extracted from electronic medication administration record (eMAR) and/or bar coding medication record (BCMA). Antimicrobials days will be collected for select antimicrobial agents (refer to Appendix B).Denominator: Days presentRequired.Days present is defined as risk for antimicrobial exposure per time unit of analysis stratified by location. For facility-wide inpatient analyses, days present is calculated as the number of patients who were present for any portion of each day of a calendar month at the facility-wide inpatient location.Appendix B. List of AntimicrobialsThe list of NHSN drug codes as well as the drug values used for the development of the CDA files can be found here: AgentAntimicrobial CategoryAntimicrobial ClassaAntimicrobial SubclassaAZTREONAMAntibacterialMonobactamsCEFEPIMEAntibacterialCephalosporinsCephalosporin 4th generationCEFTAROLINEAntibacterialCephalosporinsCephalosporins with anti- MRSA activityCEFTAZIDIMEAntibacterialCephalosporinsCephalosporin 3rd generationCEFTAZIDIME/ AVIBACTAMAntibacterialΒ-lactam/ Β-lactamase inhibitor combinationCEFTOLOZANE/ TAZOBACTAMAntibacterialΒ-lactam/ Β-lactamase inhibitor combinationDALBAVANCINAntibacterialGlycopeptidesLipoglycopeptideMEROPENEMAntibacterialCarbapenemsORITAVANCINAntibacterialGlycopeptidesLipoglycopeptidePIPERACILLIN/ TAZOBACTAMAntibacterialΒ-lactam/ Β-lactamase inhibitor combinationQUINUPRISTIN/ DALFOPRISTINAntibacterialStreptograminsTEDIZOLIDAntibacterialOxazolidinonesTELAVANCINAntibacterialGlycopeptidesLipoglycopeptidesTICARCILLIN/ CLAVULANATEAntibacterialΒ-lactam/ Β-lactamase inhibitor combinationVANCOMYCINAntibacterialGlycopeptidesGlycopeptidea Adapted from CLSI January 20143.1.5 - Reduction in Hospital Acquired Clostridium Difficile Infections This is a CDC National Healthcare Safety Network (NHSN) measure. Measure specifications follow official guidance form CDC NHSN. Specifications FAQs, and tools can be found here: Measure DescriptionStandardized infection ratio (SIR) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs)NumeratorTotal number of observed hospital-onset CDI LabID events among all inpatients in the facility, excluding well baby-nurseries and NICUsDenominatorTotal number of expected hospital-onset CDI LabID events, calculated using the facility?s number of inpatient days, bedsize, affiliation with medical school, microbiological test used to identify C. difficile, and community-onset CDI admission prevalence rate.ExclusionsData from patients who are not assigned to an inpatient bed are excluded from the denominator counts, including outpatient clinic and emergency department visits. Additionally, data from well-baby nurseries and NICUs are excluded from the denominator count.Risk AdjustmentYes ................
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