eMeasure Title

Prophylactic Antibiotic Selection for Surgical Patients

eMeasure Identifier (Measure Authoring Tool) 172 eMeasure Version number 6.2.000
NQF Number 0528 GUID feea3922-f61f-4b05-98f9-b72a11815f12
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 who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure)
Measure specifications are in the Public Domain

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This material contains SNOMED Clinical Terms (R) (SNOMED CT(C)) copyright 2004-2015 International Health Terminology Standards Development Organization. All rights reserved.
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. CMS has contracted with Mathematica Policy Research and its subcontractors, Lantana and Telligen, for the continued maintenance of this electronic measure.
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 use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. First or second-generation cephalosporins satisfy these criteria for most operations, although anaerobic coverage is needed for colon surgery. Vancomycin is not recommended for routine use because of the potential for development of antibiotic resistance, but is acceptable if a patient is allergic to beta-lactams, as are fluoroquinolones and clindamycin in selected situations.
Clinical Recommendation Statement
National guidelines recommend specific classes of antibiotics for surgical procedures. First or second-generation cephalosporins satisfy the criteria (safe, cost-effective, and coverage for most probable contaminants) for most operations, although anaerobic coverage is needed for colon surgery.
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.
American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:1839-1888.
No author listed. The Medical letter.  Antimicrobial prophylaxis for Surgery. Med Lett Drugs Ther. 2009; 82: 47-52.
Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427.
Gilbert DN, Moellering RC Jr., Elipoulos GM, Chamber HF, Saag MS, eds. The Sanford Guide to Antimicrobial Therapy  2009. 39st ed. Sperryville, VA: Antimicrobial Therapy, Inc; 2009.
Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006 Dec 21; 355 (25): 2640-2651.
Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Arch Surg. 1993;128:79-88.
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.
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.
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.
Transmission Format
Initial 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
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.
Number of surgical patients who received prophylactic antibiotics recommended for their specific surgical procedure
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