Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital (NQF 0148)

eMeasure Name Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital eMeasure Id 5C2D82F4-7179-48EF-973D-301403E3DC6E
Version number 1 eMeasure Set Id 827EFE9A-E86C-4191-957D-09CC3DEBFD64
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Oklahoma Foundation for Medical Quality
Endorsed by National Quality Forum
Description 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 Department patients prior to admission orders.
Copyright
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
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 IDSA/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 Department 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 ED prior to admission. Emergency Departments serve patients with a variety of co-morbidities such as those indicated above and varying levels of severity related to their clinical condition. The ED 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 require blood cultures for all ED 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.
Clinical Recommendation Statement
The Joint IDSA/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
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
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, 160:1399-1408.
Reference
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;31:383-421.
Reference
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. 2007 March 1;44 Suppl 2:S27-72.
Reference
Metersky ML, Ma A, Bratzler DW, et al. Predicting bacteremia in patients with community-acquired pneumonia. Am J Respir Crit Care Med 2004; 169: 342-347.
Definition
Initial Patient Population(s): All hospital discharges for pneumonia with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission who have an initial blood culture collected in the emergency department
Definition
Denominator(s): Pneumonia patients 18 years of age and older who have an initial blood culture collected as an emergency department patient with An ICD-9-CM Principal Diagnosis Code of pneumonia OR ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic)AND also a secondary ICD-9-CM Other Diagnosis Code of pneumonia , and abnormal findings on chest x-ray or CT scan of the chest within 24 hours prior to hospital arrival or during the hospitalization
Definition
Denominator Exception(s): N/A
Definition
Numerator(s): Number of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics
Definition
Denominator Exclusion(s): Patients with Cystic Fibrosis
Patients with Comfort Measures Only documented day of or day after arrival
Patients enrolled in clinical trials
Patients who have a final diagnosis/impression of pneumonia upon direct admit
Patients who had no diagnosis of pneumonia either as the ED 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 ED 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
Guidance
The measurement period is one calendar year but the reporting period is 3 months as a calendar quarter; Q1 = Jan – Mar, Q2 = Apr – Jun, Q3 = Jul – Sep, Q4 is Oct – Dec. Patients for whom there are missing or inaccurate data (e.g., arrival time, medication administration, etc.) are considered to have failed the measure; the total number of patients with missing or erroneous (e.g., a time of 03:69 or a date of 10/26/2035) data (i.e., measure failures) must be reported with the results of the measure. The measure criteria indicate scenarios in which the patient is admitted to the hospital directly (to ICU or Non-ICU locations) or the patient is admitted to one of these locations from the Emergency Department (ED). The calculation is to indicate the timing from arrival at the facility to the occurrence of an event. The arrival, therefore can be determined from the Emergency Department, the Non-ICU location, or the ICU location, whichever is the first location of contact between the patient and the facility. 

Denominator element guidance: 

For the purpose of calculating this measure, only patients who have blood cultures obtained during the ED encounter are included. ED encounter is considered ended when the patient is placed on observation or admitted status. 

Exclusion element guidance: 

The exclusion for patients who are clinical trial participants is limited to patients participating in a clinical trial for pneumonia, the same condition as covered by the measure. Other clinical trials are not valid reasons for exclusions. 

Transfers from another hospital or an Emergency Department that is not part of the hospital's organization are excluded since care may have been delivered in the other setting. The measure as specified for abstraction allowed determination of other hospital or other hospital Emergency Departments by hospital billing number. Transfers within 1 day from those hospitals or Emergency Departments using the same facility number are not considered transfers for the exclusion section of this measure, those using other facility numbers are considered exclusions.
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012