Last updated: May 17, 2016
|CMS Measure ID:||CMS172v4|
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
|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.
The measure is divided into 8 populations by type of surgery. Each denominator provides criteria for the types of surgery.
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
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.
|Measure Steward:||Centers for Medicare & Medicaid Services|
|Domain:||Efficiency and Cost Reduction Use of Healthcare Resources|
|Next Version:||Prophylactic Antibiotic Selection for Surgical Patients|
Higher score indicates better quality.
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.
Numerator element guidance:
Vancomycin is acceptable for CABG, other cardiac procedures, hip arthroplasty, knee arthroplasty and vascular surgery if there is an increased MRSA rate facility-wide or operation-specific. For the purpose of using vancomycin for prophylaxis, it is expected that vancomycin is given ONLY if one of the allowable conditions is TRUE.