Prophylactic Antibiotic Selection for Surgical Patients

Last updated: May 4, 2017

CMS Measure ID: CMS172v5
Version: 5
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

Measure Population:

Not applicable

Measure Observations:

Not applicable

Denominator Statement:

Initial Population:

The measure is divided into 8 populations by type of surgery. Each denominator provides criteria for the types of surgery

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

Denominator for population 2 - Other cardiac surgery excluding CABG

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 who had any infection prior to anesthesia
  • Patients who expired perioperatively
  • Patients who received ONLY oral or intramuscular (IM) antibiotics or the route was unable to be determined during this inpatient stay
  • Patients who received ALL antibiotics greater than 1440 minutes prior to anesthesia end date and time
  • Patients who did not receive any antibiotics within the timeframe 1440 minutes 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 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. This could also include implantation of pocketed devices.
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
Previous Version: Prophylactic Antibiotic Selection for Surgical Patients
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.

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

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Updated Denominator Exclusions in the header to align with the measure logic.
  • Updated Guidance in the header to align with the measure logic.
  • Updated Initial Population header statement to align with the measure logic.
  • eMeasure version number incremented from 5.0.000 to 5.1.000.

Logic

  • A duplicative logic sequence checking to see if a patient had antibiotics within 24 hours before the surgery throughout the rest of the inpatient encounter was removed, leaving only one check for this Denominator exclusion. Phrases removed:AND: AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM';)' <= 1440 minute(s) starts before start of 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)' AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM';)' starts after start of ('Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)' during 'Occurrence A of Encounter, Performed: Encounter Inpatient';) .
  • Changed timing relationship from 1 year to 365 days to increase specificity.
  • 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.
  • Patient Characteristic Expired is fixed to SNOMED code 419099009 (Dead) and therefore cannot be further qualified with a value set.
  • Removed the following logic from the Denominator Exclusions: OR: - AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: Substance or Medication Administration Route IV, oral or IM)' <= 1440 minute(s) starts before start of 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia' - AND NOT: 'Medication, Administered: IV, IM, PO Antimicrobial Medications (route: Substance or Medication Administration Route IV, oral or IM)' starts after start of ('Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia' during Occurrence A of $EncounterInpatient ) as it was duplicative of other logic present in the Denominator Exclusions.
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • 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 'starts before or during' (SBOD) with 'starts before end of' (SBE).
  • 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. As anesthesia does not have an incision date and time, but a start datetime and end datetime the incision datetime was removed.
  • 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

  • Additional SNOMED codes which map to ICD9CM codes were added to this value set SCIP Major Surgical Procedure (OID 2.16.840.1.113883.3.666.5.1250).
  • In the value sets for infection in the denominator exclusions, codes and concepts which represent a history of MRSA have been removed and codes and concepts which represent an active diagnosis of MRSA infection will remain. The new value set with codes and concepts representing a history of MRSA in the past will be used in numerator logic with a new datatype of 'Diagnosis, Resolved' as a reason to give Vancomycin. The OID for this value set is: 2.16.840.1.113762.1.4.1111.8.
  • 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.
  • The value set was removed from Patient Characteristic Expired: Expired as it is now fixed to a single SNOMED code: 419099009 (Dead) and cannot further be qualified with a value set.
  • 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 Acute care hospital (OID 2.16.840.1.113883.3.666.5.684): Updated value set name form Hospital Measures-Acute care hospital to Acute care hospital and deleted 15 SNOMED codes and add 1 SNOMED code.
  • Value set Acute care hospital encounter (OID 2.16.840.1.113883.3.666.5.2289): Updated the value set name from Hospital measures-Acute care hospital encounter to Acute care hospital Inpatient Encounter.
  • Value set Antibiotics for Prophylaxis for Hysterectomy Surgeries (OID 2.16.840.1.113883.3.666.5.729): Deleted 1 RXNORM code (204931).
  • 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 Beta lactams for allergy determination (OID 2.16.840.1.113883.3.666.5.1058): Updated value set name from Hospital Measures-Beta lactams for allergy determination to Beta Lactams for Allergy Determination and added 1 RXNORM code (203117).
  • 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 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 Cardiac Valve Surgery (OID 2.16.840.1.113883.3.666.5.2275): Updated value set name from Hospital Measures-Cardiac Valve Surgery to Cardiac Valve Surgery and added 46 SNOMED codes.
  • Value set Chronic Wound Care (OID 2.16.840.1.113883.3.666.5.719): Updated value set name from Hospital Measures-Chronic Wound Care to Chronic Wound Care.
  • 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 Hemodialysis or peritoneal dialysis (OID 2.16.840.1.113883.3.666.5.2282): Updated the value set name from Hospital measures-Hemodialysis or peritoneal dialysis to Hemodialysis or Peritoneal Dialysis and added 2 SNOMED codes (302497006, 71192002).
  • 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 IM or PO Antimicrobial medications (OID 2.16.840.1.113762.1.4.1045.5): Deleted 4 RXNORM codes (197456, 476193, 476299, 854812).
  • Value set IM or PO Antimicrobial Medications (OID 2.16.840.1.113762.1.4.1045.5): Deleted 5 RXNORM codes (204931, 240639, 476193, 476299, 197456).
  • Value set Intramuscular Or PO Route (OID 2.16.840.1.113762.1.4.1045.6): Updated value set name from IM or PO route to Intramuscular or PO route.
  • Value set IV Aminoglycosides (OID 2.16.840.1.113883.3.666.5.727): Updated value set name from Hospital Measures-IV Aminoglycosides to IV Aminoglycosides.
  • Value set IV Antibiotics Used For Prophylaxis For Colon Surgery (OID 2.16.840.1.113883.3.666.5.724): Updated value set name from Hospital Measures-IV Colon-Antibiotics to IV Antibiotics Used For Prophylaxis for Colon Surgery and deleted 1 RXNORM code (204931).
  • 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 Aztreonam (OID 2.16.840.1.113883.3.666.5.728): Updated value set name from Hospital Measures-IV Aztreonam to IV Aztreonam.
  • Value set IV Cefazolin (OID 2.16.840.1.113762.1.4.1045.7): Added 1 RXNORM code (1483787).
  • Value set IV Clindamycin (OID 2.16.840.1.113883.3.666.5.893): Updated value set names from Hospital Measures-IV Clindamycin to IV Clindamycin.
  • Value set IV Ertapenem (OID 2.16.840.1.113883.3.666.5.725): Updated value set name from Hospital Measures-IV Ertapenem to IV Ertapenem.
  • Value set IV Metronidazole (OID 2.16.840.1.113883.3.666.5.708): Updated value set name from Hospital Measures-IV Metronidazole to IV Metronidazole.
  • Value set IV Quinolones Used For Prophylaxis For Hysterectomy And Colon Surgery (OID 2.16.840.1.113883.3.666.5.767): Updated value set name from Hospital Measures-IV Hysterectomy and Colon Quinolones to IV Quinolones Used For Prophylaxis for Hysterectomy and Colon Surgery.
  • 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 MRSA Colonization or Infection (OID 2.16.840.1.113883.3.666.5.2278): Removed value set from this measure.
  • 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).
  • Value set Request of physician (OID 2.16.840.1.113883.3.666.5.2254): Updated value set name from Hospital measures - Request of physician to Request of physician.
  • 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 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 Substance Or Medication Administration Route IV Oral Or IM (OID 2.16.840.1.113883.3.666.5.1111): Updated the value set name from Hospital measures-Route IV, oral or IM to Substance or Medication Administration Route IV, oral or IM and deleted 1 SNOMED code (272394005).
  • 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 sets were reviewed for category or header codes and these were removed if found in the value sets.

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