Below is the most recently endorsed version of the measure specifications:
Measure Description:
Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.
Numerator Statement:
Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if receiving vancomycin, in Appendix C, Table 3.8, or a fluoroquinolone, in Appendix C, Table 3.10).
Numerator Details:
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Denominator Statement:
All selected surgical patients with no evidence of prior infection.
Denominator Details:
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Exclusions:
Excluded Populations:
• Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients whose Principal Procedure was on Table 5.25
• Patients who had a hysterectomy and a caesarean section performed during this hospitalization
• Patients who had a principal diagnosis suggestive of preoperative infectious diseases (as defined in Appendix A, Table 5.09 for ICD-9-CM codes)
• Patients enrolled in clinical trials
• Patients whose ICD-9-CM principal procedure occurred prior to the date of admission
• Patients with physician/advanced practice nurse/physician assistant (physician/APN/PA) documented infection prior to surgical procedure of interest
• Patients who had other procedures requiring general or spinal anesthesia that occurred within 3 days (4 days for CABG or Other Cardiac Surgery) prior to or after the procedure of interest (during separate surgical episodes) during this hospital stay
Exclusion Details:
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Risk Adjustment:
No risk adjustment or risk stratification
Classification:
Measure Type:
Process
Measure Format:
measure
Condition:
Surgery: Surgery
Non-Condition Specific:
Safety: Healthcare Associated Infections, Safety: Safety
Care Setting:
Inpatient/Hospital
National Quality Strategy Priorities:
Patient Safety
Current Use:
Payment Program, Public Reporting, Quality Improvement with Benchmarking (external benchmarking to multiple organizations), Regulatory and Accreditation Programs
Planned Use:
Data Source:
Claims, Other, Paper Medical Records
Level of Analysis:
Facility, Other
Target Population:
Elderly
Measure Steward Contact Information:
For additional measure specification information, please contact the Measure Steward.
Measure Steward Organization:
Centers for Medicare & Medicaid Services
Primary Measure Steward Contact:
Measure Steward Copyright:
N/A
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