Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

Last updated: May 4, 2017

CMS Measure ID: CMS171v5
Version: 5
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

Measure Population:

Not applicable

Measure Observations:

Not applicable

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 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
Previous Version: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in 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 = Oct - Dec.

Specifications

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • eMeasure version number incremented from 5.0.000 to 5.1.000.

Logic

  • Added 'during Occurrence A of $EncounterInpatient' to 'Occurrence A of Procedure, Performed: Scope Procedures' in each Numerator. Since the selected surgery 'starts after the end' of the 'scope procedure' it was necessary to time bound it to during the inpatient encounter, otherwise the selected surgery could occur at any time after the surgery and it would not necessarily have to be during this particular encounter.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the new timing operator overlaps to replace two lines of logic (AND/AND NOT) or to enforce when an event or set of events occur to meet the measure intent.
  • Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The attribute 'incision datetime' was removed from all instances of 'Procedure, Performed: General or Neuraxial Anesthesia'. This value set contains concepts related to anesthesia, not the surgery itself. Anesthesia does not have an incision date and time, but a start datetime and end datetime. These are what will be used for timing relationships when 'Procedure, Performed: General or Neuraxial Anesthesia' is the datatype used.
  • Removed logic for Clinical Trial Participant from the Denominator Exclusions.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Category and header codes were removed from all value sets.
  • Mapping from ICD9CM to SNOMED was evaluated and additional SNOMED codes were added as necessary.
  • SNOMED codes in value sets used for the data category 'diagnosis' were reviewed and were removed unless the domain was disorder, finding, situation or event.
  • Value set Abdominal hysterectomy (OID 2.16.840.1.113883.3.666.5.710): Updated value set name from Hospital measures-Abdominal hysterectomy to Abdominal Hysterectomy and deleted 1 ICD10PCS (0UTC0ZZ), 1 ICD9CM (68.31) and 3 SNOMED codes (176795006, 387645003, 414575003).
  • Value set Any infection (OID 2.16.840.1.113883.3.666.5.696): Updated value set name from Hospital Measures - Any infection to Any infection, deleted 1 ICD9CM and 62 SNOMED codes and added 245 SNOMED codes.
  • Value set CABG Surgeries (OID 2.16.840.1.113883.3.666.5.694): Updated value set name from Hospital measures-CABG to CABG Surgeries, deleted 1 SNOMED code (440332008), and added 13 SNOMED codes (119564002, 17073005, 175021005, 175022003, 175024002, 175025001, 175026000, 175029007, 405598005, 405599002, 418551006, 61236006, 8876004).
  • Value set Caesarean Section (OID 2.16.840.1.113883.3.666.5.1921): Updated value set name from Hospital Measures-Caesarean Section to Cesarean Section and added 1 SNOMED code (450484007).
  • Value set Cardiac Surgery Other Than CABG (OID 2.16.840.1.113883.3.666.5.701): Updated value set name from Hospital measures-Other Cardiac Surgery to Cardiac Surgery Other Than CABG and deleted 5 SNOMED Codes (172921000, 232855005, 232856006, 442525005, 67460004) and 1 ICD9CM code (35.98).
  • Value set Clinical Trial Participant (OID 2.16.840.1.113883.3.526.2.643): Removed value set from this measure.
  • Value set Colon surgery (OID 2.16.840.1.113883.3.666.5.705): Updated value set name from Hospital measures- Colon surgery to Colon Surgery, deleted 2 ICD9CM and 18 SNOMED codes, and added 1 ICD9CM and 14 SNOMED codes.
  • Value set Hip arthroplasty (OID 2.16.840.1.113883.3.666.5.703): Updated value set name from Hospital measures-Hip arthroplasty to Hip arthroplasty, deleted 14 ICD10PCS and 5 SNOMED codes, and added 15 SNOMED codes.
  • Value set IV Antimicrobial medication (OID 2.16.840.1.113883.3.666.5.765): Deleted 2 RXNORM codes (204931, 240639) and added 1 RXNORM code (1483787).
  • Value set IV Quinolones (OID 2.16.840.1.113883.3.666.5.835): Deleted 2 RXNORM codes (240639, 250095) and added 1 RXNORM code (250095).
  • Value set IV Vancomycin (OID 2.16.840.1.113883.3.666.5.766): Updated value set name from Hospital measures-IV Vancomycin to IV Vancomycin and added 1 RXNORM code (1421612).
  • Value set Knee arthroplasty (OID 2.16.840.1.113883.3.666.5.1816): Updated value set name from Hospital measures-Knee arthroplasty to Knee Arthroplasty Surgery. Deleted 3 SNOMED codes (179406003, 179411001, 179416006) and Added 11 SNOMED codes (179351002, 265170009, 442102003, 442655008, 443543000, 443658004, 443681002, 443682009, 444463001, 450818008, 609588000).
  • Value set SCIP Major Surgical Procedure (OID: 2.16.840.1.113883.3.117.1.7.1.2): Deleted 2 ICD9CM and 451 SNOMED codes and added 1 ICD10PCS and 98 SNOMED codes.
  • Value set Scope Procedures (OID 2.16.840.1.113762.1.4.1045.52): Updated value set name from Laparoscopic Procedures to Scope Procedures.
  • Value set Substance Or Medication Administration Route IV (OID 2.16.840.1.113883.3.666.5.1108): Updated value set name from Hospital measures-Route IV to Substance or Medication Administration Route IV.
  • Value set Vaginal hysterectomy (OID 2.16.840.1.113883.3.666.5.712): Updated value set name from Hospital measures-Vaginal hysterectomy to Vaginal Hysterectomy. Deleted 1 ICD10PCS code (0UT9FZZ) and 1 ICD9CM code (68.71), and added 9 SNOMED codes (112918004, 27185000, 30160001, 413145007, 43791001, 54490004, 63516002, 699789005, 77902002).
  • Value set Vascular surgery (OID 2.16.840.1.113883.3.666.5.713): Updated value set name from Hospital measures-Vascular surgery to Vascular Surgery and added 7 SNOMED codes (14259004, 19606007, 35653006, 405397001, 71198003, 77163008, 77773000).
  • Value set Pocketed Device Implantation Procedures (OID 2.16.840.1.113883.3.666.5.1741): Updated value set name from Hospital measures-Pacemaker or implantable defibrillator insertion procedure to Pocketed Device Implantation Procedures. Deleted 6 ICD10PCS (0JPT0PZ, 0JPT3PZ, 0KXF0ZZ, 0KXG0ZZ, 0PT10ZZ, 0PT20ZZ), 1 SNOMED (384684002), and 2 ICD9CM codes (39.86, 39.88).

XML

  • This measure contains multiple Population Criteria sections. The earlier version of this measure contained mismatches between the applicable Population Criteria human readable narrative sections and their associated computer-readable sections in the XML file. This issue has been corrected.

External Resources