Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

Last updated: May 4, 2017

CMS Measure ID: CMS171v4
Version: 4
NQF Number: 0527
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.

Initial Patient Population:

All hospital discharges for selective surgery with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission with no evidence of prior infection

Denominator Statement:

Denominator(s): All selected surgical patients 18 years of age and older with no evidence of prior infection with a Principal Procedure Code of selected surgeries.

Denominator for population 1 – Coronary artery bypass graft (CABG) procedures

Denominator for population 2 - Other cardiac surgery

Denominator for population 3 - Hip arthroplasty

Denominator for population 4 – Knee arthroplasty

Denominator for population 5 – Colon surgery

Denominator for population 6 – Abdominal hysterectomy

Denominator for population 7 – Vaginal hysterectomy

Denominator for population 8 - Vascular surgery

Denominator Exclusions:
  • Patients who had a hysterectomy and a caesarean section performed during this hospitalization
  • Patients who had a principal diagnosis suggestive of preoperative infectious diseases
  • Patients enrolled in clinical trials-this exclusion is limited to patients participating in a clinical trial for the same conditions as covered by the measure. Other clinical trials are not valid reasons for exclusion.
  • 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
Numerator Statement:

Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if receiving vancomycin or a fluoroquinolone).

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Patient Safety
Short Name: SCIPInf1
Next Version: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in the rate

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.

Denominator Exclusion guidance:

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

Specifications

External Resources