Prophylactic Antibiotic Selection for Surgical Patients

Last updated: May 17, 2016

CMS Measure ID: CMS172v4
Version: 4
NQF Number: 0528
Measure Description:

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.

Denominator Statement:

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 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 whose 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 expired perioperatively
  • 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
  • Patients who did not receive any antibiotics within the timeframe 24 hours before Surgical Incision Date and Time (i.e., patient did not receive prophylactic antibiotics) through discharge
  • Patients who received antibiotics prior to arrival and did not receive any antibiotics during this hospitalization
  • Patients who received ONLY oral or intramuscular (IM) antibiotics or the route was unable to be determined
  • Patients who received ALL antibiotics greater than 1440 minutes prior to Surgical Incision Date and Time
Numerator Statement:

Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure.

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Efficiency and Cost Reduction Use of Healthcare Resources
Short Name: SCIPInf2
Next Version: Prophylactic Antibiotic Selection for Surgical Patients
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Higher score indicates better quality.

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.

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.

Specifications

External Resources