Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

Last updated: February 1, 2017

CMS Measure ID: CMS171v6
Version: 6
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 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 neuraxial 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 (CMS)
Domain: Patient Safety
Short Name: SCIPInf1
Previous Version: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

None

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Replaced the word spinal with neuraxial anesthesia to align with value set name.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Removed definition of reporting period as reporting periods can change.

    Section: Guidance

    Source: Measure Lead

Logic

  • Added logic to link the selected surgery to the Occurrence A of the anesthesia episode in each population's denominator exclusion. An example from Population 1, the CABG surgery: AND: 'Occurrence A of Procedure, Performed: CABG Surgeries' during 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia' .

    Section: Denominator Exceptions

    Source: QDM Standards

  • Removed attribute from variable $EncounterInpatient' in all denominator exclusions. Logic originally written like this:

    —Occurrence $EncounterInpatient (principal diagnosis: Any infection)

    —'Occurrence A of Diagnosis, Active: Any infection (ordinality: Principal)' during Occurrence A of $EncounterInpatient

    has been revised to the following:

    OR: Intersection of:

    —Occurrence A of $EncounterInpatient

    —'Encounter, Performed: Encounter Inpatient (principal diagnosis: Any infection).

    Section: Denominator Exclusions

    Source: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Denominator Exclusions

    Source: QDM Standards

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic. (CMS108, CMS171, CMS172).

    Section: Denominator Exclusions

    Source: QDM Standards

  • Removed the Occurrence A from the SCIP Major Surgical Procedure Performed logic as it is not referenced elsewhere and to align with SCIP 2.

    Section: Initial Population

    Source: QDM Standards

  • Changed the value set in CMS171, CMS172 and CMS188 which was using the following OID: 2.16.840.1.113883.3.666.5.1108 to use 'Intravenous Route: 2.16.840.1.113883.3.117.1.7.1.222 for harmonization across all the eligible hospital measures.

    Section: Numerator

    Source: None

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Numerator

    Source: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

Value Set

  • Changed the value set in CMS171, CMS172 and CMS188 which was using the following OID: 2.16.840.1.113883.3.666.5.1108 to use 'Intravenous Route: 2.16.840.1.113883.3.117.1.7.1.222 for harmonization across all the eligible hospital measures.

    Section: None

    Source: JIRA (CQM-509)

  • Value set Any infection (2.16.840.1.113883.3.666.5.696): Deleted 38 SNOMEDCT codes. Deleted 49 ICD10CM codes.

    Section: None

    Source: None

  • Value set Any Infection Prior to Anesthesia Concepts (2.16.840.1.113883.3.666.5.2256): Removed ICD9CM extensional value sets (2.16.840.1.113883.3.666.5.2258 and 2.16.840.1.113883.3.666.5.902). Deleted 127 SNOMEDCT codes. Deleted 91 ICD10CM codes.

    Section: None

    Source: None

  • Value set General or Neuraxial Anesthesia (2.16.840.1.113883.3.666.5.1743): Added 3 SNOMEDCT codes (50697003, 74527005, 82776005).

    Section: None

    Source: None

  • Value set IV Antimicrobial medication (2.16.840.1.113883.3.666.5.765): Added 54 RXNORM codes and deleted 96 RXNORM codes.

    Section: None

    Source: None

  • Value set IV Quinolones (2.16.840.1.113883.3.666.5.835): Added 9 RXNORM codes (1665210, 1665212, 1665227, 1665229, 1665497, 1665507, 1665515, 1665517, 1665519) and deleted 7 RXNORM codes (199886, 200195, 240640, 309304, 315065, 895915, 998756).

    Section: None

    Source: None

  • Value set Pocketed Device Implantation Procedures (2.16.840.1.113883.3.666.5.1741): Added 89 ICD10PCS codes.

    Section: None

    Source: None

  • Value set Vaginal Hysterectomy (2.16.840.1.113883.3.666.5.712): Deleted 2 ICD10PCS codes (0UT48ZZ, 0UT98ZZ). Removed ICD9CM extensional value set (2.16.840.1.113883.3.666.5.1827) including 3 codes. Deleted 1 SNOMEDCT code (75835007).

    Section: None

    Source: None

  • Value set Vascular Surgery (2.16.840.1.113883.3.666.5.713): Deleted 1 SNOMEDCT code (3546002).

    Section: None

    Source: None

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