Prophylactic Antibiotic Selection for Surgical Patients

Last updated: July 12, 2017

CMS Measure ID: CMS172v6
Version: 6
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 period for patients age 18 and older at the time of hospital admission

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 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. 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 (CMS)
Domain: Efficiency and Cost Reduction Use of Healthcare Resources
Short Name: SCIPInf2
Previous Version: Prophylactic Antibiotic Selection for Surgical Patients
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

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.

Addendum Notes: Removed from Hospital Quality Reporting

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

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

    —Occurrence A of &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

  • Removed 'route' attribute from Medication, Active to align with measure intent.

    Section: Denominator Exclusions

    Source: JIRA (CQM-1660)

  • 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.

    Section: Denominator Exclusions

    Source: QDM Standards

  • Value set Intravenous route (2.16.840.1.113883.3.117.1.7.1.222): Added Intravenous route.

    Section: Denominator Exclusions

    Source: None

  • Value set Substance or Medication Administration Route IV (2.16.840.1.113883.3.666.5.1108): Removed Substance or Medication Administration Route IV.

    Section: Denominator Exclusions

    Source: None

  • Removed Occ A from Procedure performed: SCIP Major Surgical Procedure as it is not referenced elsewhere and to align with SCIP 1.

    Section: Initial Population

    Source: Measure Lead

  • Changed logic in the numerator of all 8 populations in SCIP2 so that the procedure in each population will be bound to the surgical episode represented by: 'Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia'.

    Section: Numerator

    Source: Measure Lead

  • Removed attribute 'discharge datetime' from 'Encounter, Performed: Encounter Inpatient' as the timing in the logic indicates the end of the encounter.

    Section: Numerator

    Source: Measure Lead

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

    Section: Numerator

    Source: QDM Standards

  • Replaced the current 'History of MRSA Colonization or Infection' logic as a reason for giving Vancomycin to the following logic:

    'Diagnosis: MRSA Colonization or Infection' satisfies any:

    starts before start of 'Occurrence A of Procedure, Performed: CABG Surgeries (incision datetime)'

    overlaps 'Occurrence A of Procedure, Performed: CABG Surgeries (incision datetime)'.

    Section: Numerator

    Source: JIRA (CQM-1745)

  • Value set Intravenous route (2.16.840.1.113883.3.117.1.7.1.222): Added Intravenous route.

    Section: Numerator

    Source: None

  • Value set Substance or Medication Administration Route IV (2.16.840.1.113883.3.666.5.1108): Removed Substance or Medication Administration Route IV.

    Section: Numerator

    Source: None

  • 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 Intravenous route (2.16.840.1.113883.3.117.1.7.1.222): Added Intravenous route.

    Section: QDM Data Elements

    Source: None

  • Value set Substance or Medication Administration Route IV, oral or IM (2.16.840.1.113883.3.666.5.1111): Renamed Substance or Medication Administration Route IV, oral or IM to Route IV, oral or IM.

    Section: QDM Data Elements

    Source: None

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)

  • The value sets that were included in the grouping value set 'History of MRSA Colonization or Infection' were changed to represent 'MRSA Colonization or Infection', including history of MRSA infection, current MRSA infection, colonization of MRSA, a positive MRSA screen.

    Section: None

    Source: JIRA (CQM-1745)

  • Value set Acute care hospital Inpatient Encounter (2.16.840.1.113883.3.666.5.2289): Deleted 4 SNOMEDCT codes (183497001, 305335007, 32485007, 8715000).

    Section: None

    Source: None

  • Value set Antibiotics for Prophylaxis for Hysterectomy Surgeries (2.16.840.1.113883.3.666.5.729): Added 24 RXNORM codes and deleted 23 RXNORM codes.

    Section: None

    Source: None

  • 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 Beta Lactams for Allergy Determination (2.16.840.1.113883.3.666.5.1058): Deleted 5 RXNORM codes (214233, 2183, 2239, 267073, 6927).

    Section: None

    Source: None

  • Value set CABG Surgeries (2.16.840.1.113883.3.666.5.694): Added 1 SNOMEDCT code (232722009) and deleted 1 SNOMEDCT code (61236006).

    Section: None

    Source: None

  • Value set Cefuroxime and Cefazolin Antibiotics for IV Administration (2.16.840.1.113883.3.666.5.768): Added 6 RXNORM codes (1665050, 1665052, 1665060, 1665444, 1665447, 1665449) and deleted 11 RXNORM codes (204929, 309051, 309052, 309053, 309099, 309100, 313929, 796301, 854220, 904288, 997632).

    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 Hemodialysis or Peritoneal Dialysis (2.16.840.1.113883.3.666.5.2282): Added 2 SNOMEDCT codes (708931003, 708932005).

    Section: None

    Source: None

  • Value set IM or PO Antimicrobial medications (2.16.840.1.113762.1.4.1045.5): Added 15 RXNORM codes and deleted 55 RXNORM codes.

    Section: None

    Source: None

  • Value set Intravenous route (2.16.840.1.113883.3.117.1.7.1.222): Added Intravenous route.

    Section: None

    Source: None

  • Value set IV Aminoglycosides (2.16.840.1.113883.3.666.5.727): Added 3 RXNORM codes (1723156, 1723160, 1727174) and deleted 3 RXNORM codes (415059, 905143, 905148).

    Section: None

    Source: None

  • Value set IV Antibiotics Used For Prophylaxis for Colon Surgery (2.16.840.1.113883.3.666.5.724): Added 7 RXNORM codes (1659592, 1659598, 1665102, 1665107, 1722916, 1722919, 1722921) and deleted 12 RXNORM codes.

    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 Aztreonam (2.16.840.1.113883.3.666.5.728): Added 2 RXNORM codes (1664981, 1664986) and deleted 3 RXNORM codes (308466, 308467, 308468).

    Section: None

    Source: None

  • Value set IV Cefazolin (2.16.840.1.113762.1.4.1045.7): Added 3 RXNORM codes (1665050, 1665052, 1665060) and deleted 7 RXNORM codes (1483787, 309051, 309052, 309053, 313929, 796301, 854220).

    Section: None

    Source: None

  • Value set IV Ceftriaxone (2.16.840.1.113762.1.4.1045.3): Added 3 RXNORM codes (1665005, 1665021, 1665046) and deleted 3 RXNORM codes (204871, 309091, 309093).

    Section: None

    Source: None

  • Value set IV Cefuroxime (2.16.840.1.113762.1.4.1045.8): Added 2 RXNORM codes (1665444, 1665449) and deleted 5 RXNORM codes (204929, 309099, 309100, 904288, 997632).

    Section: None

    Source: None

  • Value set IV Quinolones Used For Prophylaxis for Hysterectomy and Colon Surgery (2.16.840.1.113883.3.666.5.767): Added 9 RXNORM codes (1665210, 1665212, 1665227, 1665229, 1665497, 1665507, 1665515, 1665517, 1665519) and deleted 4 RXNORM codes (199886, 309304, 895915, 998756).

    Section: None

    Source: None

  • Value set IV, IM, PO Antimicrobial Medications (2.16.840.1.113883.3.666.5.693): Deleted 146 RXNORM codes.

    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 Route IV, oral or IM (2.16.840.1.113883.3.666.5.1111): Deleted 2 SNOMEDCT codes (447963004, 449137004).

    Section: None

    Source: None

  • Value set Substance or Medication Administration Route IV (2.16.840.1.113883.3.666.5.1108): Removed Substance or Medication Administration Route IV.

    Section: None

    Source: None

  • Value set Substance or Medication Administration Route IV, oral or IM (2.16.840.1.113883.3.666.5.1111): Renamed Substance or Medication Administration Route IV, oral or IM to Route IV, oral or IM.

    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

External Resources