eMeasure Title

Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

eMeasure Identifier (Measure Authoring Tool) 171 eMeasure Version number 6.3.000
NQF Number 0527 GUID d09add1d-30f5-462d-b677-3d17d9ccd664
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Developer Oklahoma Foundation for Medical Quality
Endorsed By National Quality Forum
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.
Measure specifications are in the Public Domain.

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Measure Scoring Proportion
Measure Type Process
Measure Item Count
Encounter, Performed: Encounter Inpatient
Risk Adjustment
Rate Aggregation
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision. Studies performed in the 1960's and 1970's demonstrated that a common reason for failure of prophylaxis was delay of antibiotic administration until after the operation. In a study of 2,847 surgery patients at LDS Hospital in Salt Lake City, it was found that the lowest incidence of post-operative infection was associated with antibiotic administration during the one hour prior to surgery. The risk of infection increased progressively with greater time intervals between administration and skin incision. This relationship was observed whether antibiotics preceded or followed skin incision (Classen 1993). Opportunities to improve care have been demonstrated and timely administration has been recommended. For example, at LDS Hospital, administration of the first antibiotic dose "on call" to the operating room was frequently associated with timing errors. Altering the system there resulted in an increase in appropriate timing from 40% of cases in 1985 to 99% of cases in 1998.
Clinical Recommendation Statement
Improvement Notation
Improvement noted as an increase in rate
Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers Group. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. CID. 2004:38(15 June):1706-1715.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. Am J Surg. 1996;171:548-552.
Larsen RA, Evans RS, Burke JP, et al. Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol. 1989;10:316-320.
Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097.
Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care: administration of preoperative antibiotics in the operating room. Am Surg. 1997;63:500-503.
Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients undergoing common surgical procedures in a community teaching hospital: the chaos continues. World J Surg. 1999;23:429-432.
Bernard HR, Cole WR. The prophylaxis of surgical infections: the effect of prophylactic antimicrobial drugs on the incidence of infection following potentially contaminated operations. Surgery. 1964;56:151-157.
Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969;66:97-103.
Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary, and colonic surgery. Ann Surg. 1976;184:443-452.
American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.
Transmission Format
Initial 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(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
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
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity, and sex

Table of Contents

Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set
Surgical Care Improvement Project