Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients

Last updated: May 15, 2017

CMS Measure ID: CMS188v6
Version: 6
NQF Number: 0147
Measure Description:

(PN-6) Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines

(Population 1) Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines

(Population 2) Immunocompetent non-Intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines

Initial Patient Population:

Pneumonia patients 18 years of age and older at the time of admission to inpatient care with a discharge principal diagnosis of pneumonia, OR Principal Diagnosis of septicemia or respiratory failure (acute or chronic) AND also a secondary other diagnosis code of pneumonia. Patient with a LOS <=120 days and discharged during the measurement period.

This measure is divided into patients admitted to the intensive care unit (ICU population 1), and those admitted to non-ICU hospital locations (population 2).

For both populations, arrival at the hospital means either arrival at the ED or arrival as a direct admit to the inpatient setting.

Denominator Statement:

ICU population:

Patients who meet the Initial Population and:

  • Arrival at hospital is either arrival in ED or arrival to floor as direct admit
  • Admitted to ICU within 24 hours after arrival at hospital with reasons for admission due to pneumonia
  • Pneumonia related reasons for admission to ICU include:
    • Septic shock
    • Respiratory distress or failure
    • Hypotension
    • Tachypnea
    • Hypoxemia
    • Need for a ventilator
    • Tachycardia
  • Diagnosis of pneumonia documented within 24 hours after arrival; if seen in ED diagnosis must be documented in ED
  • Antibiotics received within 24 hours of arrival or within 1 day prior to hospital arrival and during hospital stay.

Non-ICU population:

Patient who meet the Initial Population and:

  • Arrival at hospital is either arrival in ED or arrival to floor as direct admit
  • Diagnosis of pneumonia documented within 24 hours after arrival; if seen in ED diagnosis must be documented in ED
  • Antibiotics received within 24 hours after arrival
Denominator Exclusions:

ICU Population only:

Patients transferred/admitted to the ICU within 24 hours after arrival to this hospital, with a beta-lactam allergy (population 1 only).

For patients in both ICU and non-ICU the rest of the denominator exclusions are the same:

  • Patients with either a normal Chest X-ray or a normal CT scan which includes the chest within 1 day prior to arrival at the hospital or during the hospitalization
  • Patients who have Comfort Measures documented as performed or ordered on the day of or the day after arrival at the hospital or after arrival in the ED
  • Patients who are transferred from one of the following within 24 hours before the start of the ED encounter or the hospital encounter:
    • An acute care hospital
    • An ambulatory surgical center
    • A transfer from an emergency department of an outside hospital
    • A transfer from an outpatient department of an outside hospital
  • Patients who were an inpatient less than or equal to 1 day.

The following exclusions are reasons for alternative empiric antibiotic therapy:

  • Patients who have a diagnosis of a prolonged QT interval documented within 24 hours after arrival at the ED or the hospital
  • Patients who have a diagnosis of an immunocompromised condition within the last 90 days before arrival at the ED or arrival at the hospital or during the hospitalization
  • Patients who have significant neutropenia, which is defined as a Neutrophil count of <500 per mm3 within the last 90 days before arrival at the ED or arrival at the hospital or during the hospitalization
  • Patients who have any of the following within 30 days before arrival at the ED or arrival at the hospital:
    • Hemodialysis or peritoneal dialysis
    • Wound care
    • Tracheostomy care
    • Ventilator care
    • Diagnosis of healthcare associated pneumonia
  • Patients who have any of the following which starts before the end of the inpatient hospitalization:
    • Immunodeficient conditions
    • Cystic Fibrosis
    • History of an organ transplant
  • Patients who have any of the following within 90 days before the start of either the ED or the direct admit:
    • Immunocompromised Therapies (radiation treatments, for instance)
    • Systemic Immunosuppressive therapy (chemotherapy, for instance)
    • A patient in a nursing home or an extended care facility
    • A patient in another acute care hospital
Numerator Statement:

Pneumonia patients who received an initial antibiotic regimen consistent with current guidelines during the first 24 hours of their hospitalization.

Numerator 1 (in population 1) defines appropriate antibiotics for ICU patients.

Numerator 2 (in population 2) defines appropriate antibiotics for non-ICU patients.

Non-ICU patients are evaluated for pseudomonal risk.

Pseudomonal risk requires certain antibiotics per clinical guidelines.

Pseudomonal risk includes:

  • Bronchiectasis
  • Structural lung disease which includes the following:
    • Diagnosis: COPD
    • Diagnosis: Chronic bronchitis
    • Diagnosis: Emphysema
    • Diagnosis: Interstitial lung disease
    • Diagnosis: Restrictive lung disease
    • Diagnosis: Structural lung disease
Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Pneumonia patients with Another Source of Infection who did not receive an antibiotic regimen recommended for pneumonia, but did receive antibiotics within the first 24 hours of hospitalization. Pneumonia patients who have been on systemic corticosteroid/prednisone therapy within the last 90 days prior to arrival to the hospital.

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Efficiency and Cost Reduction Use of Healthcare Resources
Short Name: PN6
Previous Version: Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

General guidance:

The measure criteria indicate scenarios in which the patient is admitted to the hospital directly (to ICU or Non-ICU locations) or the patient is admitted to one of these locations from the Emergency Department (ED).

The calculation is to indicate the timing from arrival at the facility to the occurrence of an event. The arrival, therefore can be determined from the Emergency Department, the Non-ICU location, or the ICU location, whichever is the first location of contact between the patient and the facility.

Exclusion element guidance:

Transfers from another hospital that is not part of the hospital's organization are excluded since care may have been delivered in the other setting. The measure as specified for abstraction allowed determination of other hospitals by hospital billing number.

Transfers within 1 day from those hospitals using the same facility number are not considered transfers for the exclusion section of this measure, those using other facility numbers are considered exclusions.

Respiratory Infection exclusion- the logic indicates that the patient is included if they have a respiratory infection but excluded for any other infection unless the encounter ends <=24 hr after the start.

The exclusion for absolute neutrophil count < 500 may require calculation. The absolute neutrophil count (ANC) = Total WBC x (% Segs + % Bands), OR WBC x ((Segs/100) + (Bands/100)).

Addendum Notes: Removed from Hospital Quality Reporting

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • ​Removed the word Active from diagnosis of immunocompromised condition to align with logic.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Removed the word acute from inpatient statement to align with logic.

    Section: Initial Population

    Source: Measure Lead

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

    Section: Numerator

    Source: QDM Standards

Logic

  • Inline comments added to provide clarification to logic sections.

    Section: None

    Source: Measure Lead

  • Changed all attributes for route which were on the left hand side of the phrase so that they were after the 'satisfies all' or 'satisfies any' which put them on the right hand side of the logic phrase.

    Section: Denominator

    Source: JIRA (CQM-1690)

  • Changed the denominator logic so that it is either looking for a 'Medication, Administered' within 24 hours of the inpatient encounter start time or 'Medication, Active' within 24 hours prior to the inpatient encounter start time.

    Section: Denominator

    Source: JIRA (CQM-1679)

  • 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: Denominator

    Source: JIRA (CQM-509)

  • Removed the route attribute from all the Medication, Active logic in the denominator in both the ICU and non-ICU population.

    Section: Denominator

    Source: Measure Lead

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

    Section: Denominator

    Source: QDM Standards

  • 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: Denominator

    Source: None

  • Added timing of <= 1 hour(s) to this logic in the non-ICU population that states a patient is seen in the ED and that the ED visit ends before the start of (within 1 hour) or concurrent with the start of the Inpatient Encounter.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Changed Medication, Administered datatype to Medication, Active datatype in the Denominator Exceptions logic in both the ICU and non-ICU populations.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Removed the route attribute from the Medication, Active logic in the Denominator Exceptions logic in the ICU and non-ICU populations.

    Section: Denominator Exceptions

    Source: Measure Lead

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

    Section: Denominator Exceptions

    Source: QDM Standards

  • Changed all logic where 3 months is used to say 90 days, which harmonizes the 3 month and 90 day timings throughout the measure.

    Section: Denominator Exclusions

    Source: Measure Lead

  • Extended the temporal operators to 'starts before or concurrent with start of' and 'ends before or concurrent with start of' to provide for greater flexibility to hospitals in fulfilling the 'Transfer From' statements.

    Section: Denominator Exclusions

    Source: JIRA (CQM-1656)

  • Removed the route attribute from the Medication, Active logic in the Denominator logic in the ICU and non-ICU populations.

    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

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

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

    Section: Initial Population

    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: Initial Population

    Source: QDM Standards

  • Changed all attributes for route which were on the left hand side of the phrase so that they were after the 'satisfies all' or 'satisfies any' which put them on the right hand side of the logic phrase.

    Section: Numerator

    Source: JIRA (CQM-1690)

  • Changed Medication, Administered datatype to Medication, Active datatype in the pseudomonal risk factor section of the logic in the numerator of the non-ICU patient logic.

    Section: Numerator

    Source: Measure Lead

  • Removed the route attribute from the Medication, Active logic in the Numerator logic in the non-ICU population.

    Section: Numerator

    Source: Measure Lead

  • 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. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ 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 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)

  • 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 Ambulatory surgical center (2.16.840.1.113883.3.666.5.687): Added 2 SNOMEDCT codes (10531005, 69362002).

    Section: None

    Source: None

  • Value set Another Source of Infection (2.16.840.1.113762.1.4.1111.28): Deleted 4 SNOMEDCT codes (111181004, 25957002, 286998005, 53295002).

    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 Diagnoses as Reasons For Admission to ICU due to Pneumonia (2.16.840.1.113762.1.4.1045.84): Added 3 SNOMEDCT codes (101301000119106, 709110009, 709111008).

    Section: None

    Source: None

  • Value set Emergency department location (2.16.840.1.113762.1.4.1111.14): Added 1 SNOMEDCT code (73770003).

    Section: None

    Source: None

  • Value set Francisella Tularensis or Yersinia pestis (2.16.840.1.113883.3.666.5.2205): Added 8 SNOMEDCT codes (186293006, 21857006, 34023009, 37722001, 398554008, 398575000, 398599000, 73363000).

    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 Immunocompromised Conditions (2.16.840.1.113883.3.666.5.1940): Added 7 SNOMEDCT codes (234646005, 402355000, 402356004, 402357008, 402358003, 444547006, 47650006) and deleted 1 SNOMEDCT code (80255009). Added 1 ICD10CM code (C86.6).

    Section: None

    Source: None

  • Value set Immunodeficient Conditions (2.16.840.1.113883.3.666.5.1726): Deleted 2 SNOMEDCT codes (402916007, 431347008).

    Section: None

    Source: None

  • Value set Interstitial lung disease (2.16.840.1.113883.3.666.5.777): Deleted 38 SNOMEDCT codes. Added 22 ICD10CM codes.

    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 Antipneumococcal/antipseudomonal beta lactams (2.16.840.1.113883.3.666.5.759): Added 9 RXNORM codes (1659131, 1659149, 1665088, 1665093, 1665097, 1722934, 1722939, 1726204, 1726214) and deleted 11 RXNORM codes (1043464, 309055, 309056, 309057, 309292, 311549, 312443, 312446, 313922, 581374, 998355).

    Section: None

    Source: None

  • Value set IV Antipseudomonal quinolones (2.16.840.1.113883.3.666.5.896): 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 Beta lactams (2.16.840.1.113883.3.666.5.770): Added 7 RXNORM codes (1656313, 1656318, 1659592, 1659598, 1665005, 1665021, 1665046) and deleted 9 RXNORM codes (198395, 198396, 204871, 308208, 309066, 309067, 309091, 309093, 993109).

    Section: None

    Source: None

  • Value set IV Macrolides ICU (2.16.840.1.113883.3.666.5.758): Added 2 RXNORM codes (1668238, 1668264) and deleted 8 RXNORM codes (308461, 310163, 597298, 686354, 686447, 891294, 997999, 998004).

    Section: None

    Source: None

  • Value set IV or IM Aztreonam (2.16.840.1.113883.3.666.5.779): Added 2 RXNORM codes (1664981, 1664986) and deleted 3 RXNORM codes (308466, 308467, 308468).

    Section: None

    Source: None

  • Value set IV or IM Beta lactams (2.16.840.1.113883.3.666.5.720): Added 7 RXNORM codes (1656313, 1656318, 1659592, 1659598, 1665005, 1665021, 1665046) and deleted 10 RXNORM codes (198395, 198396, 204871, 308208, 309066, 309067, 309091, 309093, 313819, 993109).

    Section: None

    Source: None

  • Value set IV or PO Doxycyclines (2.16.840.1.113883.3.666.5.840): Added 13 RXNORM codes and deleted 7 RXNORM codes (197633, 199026, 199027, 310029, 310030, 359465, 597808).

    Section: None

    Source: None

  • Value set IV or PO Levofloxacin (2.16.840.1.113883.3.666.5.760): Added 5 RXNORM codes (1665497, 1665507, 1665515, 1665517, 1665519) and deleted 2 RXNORM codes (199886, 895915).

    Section: None

    Source: None

  • Value set IV or PO Macrolides Non ICU (2.16.840.1.113883.3.666.5.772): Added 2 RXNORM codes (1668238, 1668264) and deleted 13 RXNORM codes.

    Section: None

    Source: None

  • Value set IV PO AntiPseudomonal Quinolones (2.16.840.1.113883.3.666.5.804): 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 PO Quinolone Antipneumococcal (2.16.840.1.113883.3.666.5.463): Added 5 RXNORM codes (1665497, 1665507, 1665515, 1665517, 1665519) and deleted 2 RXNORM codes (199886, 895915).

    Section: None

    Source: None

  • Value set IV Quinolones Antipneumococcal (2.16.840.1.113883.3.666.5.465): Added 5 RXNORM codes (1665497, 1665507, 1665515, 1665517, 1665519) and deleted 2 RXNORM codes (199886, 895915).

    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 Pneumonia (2.16.840.1.113883.3.666.5.752): Added 1 SNOMEDCT code (195889001) and deleted 1 SNOMEDCT code (312403005).

    Section: None

    Source: None

  • Value set Procedures as Reasons for Admission to ICU Due to Pneumonia (2.16.840.1.113762.1.4.1111.26): Added 1 SNOMEDCT code (40617009) and deleted 1 SNOMEDCT code (243142003).

    Section: None

    Source: None

  • Value set Respiratory failure acute or chronic (2.16.840.1.113883.3.666.5.2319): Added 3 SNOMEDCT codes (101301000119106, 709110009, 709111008).

    Section: None

    Source: None

  • Value set Respiratory infection (2.16.840.1.113883.3.666.5.2162): Deleted 4 SNOMEDCT codes (233607000, 53084003, 76090006, 81164001). Deleted 7 ICD10CM codes (A37.91, J15.6, J15.8, J15.9, J18.1, J18.8, J18.9).

    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 Route IV/IM (2.16.840.1.113883.3.666.5.1109): Deleted 2 SNOMEDCT codes (447963004, 449137004).

    Section: None

    Source: None

  • Value set Structural lung disease (2.16.840.1.113883.3.666.5.774): Added 10 ICD10CM codes (J62.0, J63.2, J63.3, J63.4, J66.8, J67.2, J67.5, J67.6, J67.7, J67.9). Added 28 SNOMEDCT codes.

    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 Systemic corticosteroid/prednisone therapy (2.16.840.1.113883.3.666.5.805): Deleted 19 RXNORM codes.

    Section: None

    Source: JIRA (CQM-1713)

  • Value set Systemic immunosuppressive therapy (2.16.840.1.113883.3.666.5.803): Added 5 RXNORM codes (1656643, 1656648, 1726324, 1726333, 1726492) and deleted 133 RXNORM codes.

    Section: None

    Source: JIRA (CQM-1713)

External Resources