National Hospital Inpatient Quality Reporting Measures Specifications Manual Release Notes

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1 Natinal Hspital Inpatient Quality Reprting Measures Specificatins Manual Release Ntes Fr Manual Versin: 5.4 Cmpleted: Nvember 27, 2017 Guidelines fr Using Release Ntes The Release Ntes prvides mdificatins t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures, Versin 5.4. The infrmatin in this dcument is t be used as a reference and is nt intended t be used t prgram abstractin tls. Please refer t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures fr the cmplete and current technical specificatins and abstractin infrmatin. The ntes are rganized t fllw the rder f the Table f Cntents. The implementatin date is 07/01/2018, unless therwise specified. The headings are described belw: Impacts - used t identify the impacted measures and prtin(s) f the Manual Sectin, e.g., Alphabetical Data Dictinary, Measure Infrmatin Frm (MIF) and Flwchart (Algrithm). Descriptin f Changes - used t identify the sectin within the dcument where the change ccurs, e.g., Definitin, Data Cllectin Questin, Allwable Values, and Denminatr Statement - Data Elements. Ratinale - prvided fr the change being made. Data elements that crss multiple measures and cntain the same changes will be cnslidated. NOTE: In additin t being called ut specifically in the Release Ntes dcument, additins are yellw highlighted in the crrespnding dcuments. The changes in the Hspital Initial Patient Ppulatin and Clinical Data XML File Layuts have yellw highlighted cells with actual changes nted in bld fnt.

2 Table f Cntents Release Ntes Versin 5.4 Nte: click n any sectin title in the Release Ntes t return t Table f Cntents page. Table f Cntents (n updates)... 2 Acknwledgement (n updates)... 2 Intrductin (n updates)... 2 Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates)... 2 SECTION 1 Data Dictinary... 2 Intrductin t Data Dictinary (n updates)... 2 Alphabetical Data Dictinary... 2 SECTION 2 Measurement Infrmatin Subsectin 2.1 Severe Sepsis and Septic Shck (SEP) Subsectin 2.2 Venus Thrmbemblism (VTE) (n updates) Subsectin 2.4 Glbal Initial Patient Ppulatin (ED, IMM, TOB, SUB) Subsectin 2.5 Emergency Department (ED) (n updates) Subsectin Preventin Immunizatin (IMM) (n updates) Substance Use (SUB) (n updates) Tbacc Treatment (TOB) SECTION 3 Missing and Invalid Data (n updates) SECTION 4 Ppulatin and Sampling Specificatins (n updates) SECTION 9 Data Transmissin Transmissin Overview (n updates) Transmissin Alphabetical Data Dictinary (n updates) Hspital Clinical Data XML File Layut Hspital Initial Patient Ppulatin Data XML File Layut (n updates) SECTION 10 CMS Outcme/Structural Measures Subsectin 10.1 CMS Outcme Measures (n updates) Subsectin 10.2 Structural Measures (n updates) APPENDICES Appendix A ICD-10 Cde Tables (Wrd and Excel) Appendix C Medicatin Tables (Wrd and Excel) Appendix D Glssary f Terms (n updates) Appendix E Overview f Measure Infrmatin Frm and Flwchart Frmats (n updates) Appendix F Measure Name Crsswalk (n updates) Appendix G Resurces (n updates) Appendix H Miscellaneus Tables Appendix P Preview Sectin (n updates) Specificatins Manual fr Hspital Inpatient Quality Measures Page 1

3 The cntent belw is rganized t fllw the Table f Cntents in the specificatins manual. Table f Cntents (n updates) Acknwledgement (n updates) Intrductin (n updates) Using the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures (n updates) SECTION 1 Data Dictinary Intrductin t Data Dictinary (n updates) Alphabetical Data Dictinary Administrative Cntraindicatin t Care, Septic Shck Ratinale: The Administrative Cntraindicatin t Care, Septic Shck data element is being updated t prvide additinal guidance. Suggested Data Cllectin Questin Change frm: Did the patient r surrgate decisin-maker decline cnsent fr bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck? T: Is there dcumentatin that the patient r authrized patient advcate refused either a bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing the Septic Shck Presentatin Time? Allwable Values Change frm: 1 (Yes) There is dcumentatin by a physician/apn/pa r nurse that the patient r decisinmaker has refused either bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck. 2 (N) There is n physician/apn/pa r nurse dcumentatin that the patient r decisinmaker has refused either bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck. T: 1 (Yes) There is dcumentatin by a physician/apn/pa r nurse that the patient r authrized patient advcate has refused either bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck. Specificatins Manual fr Hspital Inpatient Quality Measures Page 2

4 2 (N) There is n physician/apn/pa r nurse dcumentatin that the patient r authrized patient advcate has refused either bld draw, IV fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck. Ntes fr Abstractin Change t: Only acceptable surces are physician/apn/pa r nursing dcumentatin. Specific dcumentatin indicating patient r authrized patient advcate has refused the fllwing can be used t select Value 1. Bld draws IV r IO fluid administratin Vaspressrs A mre general dcumentatin f refusal f care (e.g. central line, PICC, IO access) that wuld result in the fllwing nt being administered is acceptable. Bld Draws IV r IO fluid administratin Vaspressrs Fr refusal f bld draws: Suggested Data Surces Add new bullet pint: Nursing Ntes Dcumented refusal f bld draws is acceptable. Refusal f specific bld draws r bld tests that d nt impact the ability t meet the requirements f the SEP-1 measure data elements shuld nt be used. Examples: Patient refused HIV bld test. Patient refused arterial bld gas (ABG). Inclusin Guidelines fr Abstractin Add new bullet pint: Des nt want Administrative Cntraindicatin t Care, Severe Sepsis Ratinale: The Administrative Cntraindicatin t Care, Severe Sepsis data element is being updated t prvide additinal guidance. Suggested Data Cllectin Questin Change frm: Did the patient r surrgate decisin-maker decline cnsent fr bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis? Specificatins Manual fr Hspital Inpatient Quality Measures Page 3

5 T: Is there dcumentatin that the patient r authrized patient advcate refused either a bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing the Severe Sepsis Presentatin Time? Allwable Values Change frm: 1 (Yes) There is dcumentatin by a physician/apn/pa r nurse that the patient r decisinmaker has refused either bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis. 2 (N) There is n physician/apn/pa r nurse dcumentatin that the patient r decisinmaker has refused either bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis. T: 1 (Yes) There is dcumentatin by a physician/apn/pa r nurse that the patient r authrized patient advcate has refused either bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis. 2 (N) There is n physician/apn/pa r nurse dcumentatin that the patient r authrized patient advcate has refused either bld draw, IV fluid administratin, r IV antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis. Ntes fr Abstractin Change t: Only acceptable surces are physician/apn/pa r nursing dcumentatin. Specific dcumentatin indicating patient r authrized patient advcate has refused the fllwing can be used t select Value 1. Bld draws IV r IO fluid administratin IV r IO antibitic A mre general dcumentatin f refusal f care that wuld result in the fllwing nt being administered is acceptable. Bld draws IV r IO fluid administratin IV r IO antibitic Fr refusal f bld draws: Suggested Data Surces Add new bullet pint: Nursing Ntes Dcumented refusal f bld draws is acceptable. Refusal f specific bld draws r bld tests that d nt impact the ability t meet the requirements f the SEP-1 measure data elements shuld nt be used. Examples: Patient refused HIV bld test. Patient refused arterial bld gas (ABG). Specificatins Manual fr Hspital Inpatient Quality Measures Page 4

6 Inclusin Guidelines fr Abstractin Add new bullet pint: Des nt want Alchl Use Status Ratinale: The data element is being updated t prvide clarificatin fr abstractin f cgnitive impairment. Ntes fr Abstractin Change t: The alchl use status screening must have ccurred within the first day f admissin (by end f Day 1). This includes the day f admissin which is defined as Day 0 and the day after admissin which is defined as Day 1. EXCEPTION: If the screening was perfrmed within 3 days prir t admissin, i.e., at the transferring facility, in anther inpatient hspital unit, emergency department r bservatin unit, the screening dcumentatin must be present in the current medical recrd. If patient has a bld alchl test with a result f.08 g/dl r greater r the clinician dcuments the patient was acutely intxicated per bld alchl test results select Value 2. The 0.08 limit is a bld alchl cncentratin (BAC) reprted in g/dl. If results are given in mg/dl, cnvert t g/dl by mving the decimal pint 3 places t the left. Examples: A 100 mg/dl serum ethanl level is equivalent t a 0.10 (g/dl) BAC. An 80 mg/dl serum ethanl level is equivalent t a 0.08 g/dl BAC. Screening may be dne with a validated Single Alchl Screening Questin (SASQ) in rder t identify thse patients with n risk r lw risk r wh d nt drink. Further screening shuld be dne with a validated tl fr thse patients with a psitive result t determine if there is need fr a brief interventin. Examples f SASQs include: On any single ccasin during the past 3 mnths, have yu had mre than 5 drinks cntaining alchl? (Yes respnse is cnsidered psitive.) "When was the last time yu had mre than X drinks in 1 day?" (X = 4 fr wmen and 5 fr men) (Within the last 3 mnths is cnsidered psitive.) Hw many times in the past year have yu had X r mre drinks in a day?" (X = 5 men and 4 wmen) (Respnse f >1 is cnsidered psitive.) Hw ften have yu had 6 r mre drinks n ne ccasin in the past year? (Ever in the past year cnsidered psitive.) Hw ften d yu have X r mre drinks n ne ccasin? (X = 4 fr wmen and 5 fr men) (Ever in the past year cnsidered psitive.) Refer t the Inclusin Guidelines fr examples f cmmnly used validated screening tls; nte that the CAGE, althugh a validated tl, is nt recmmended fr this measure set. Specificatins Manual fr Hspital Inpatient Quality Measures Page 5

7 If there is dcumentatin in the medical recrd indicating the patient drinks alchl and cnflicting dcumentatin indicating the patient des nt drink alchl, select Value 6 since alchl use status is unable t be determined. When there is cnflicting infrmatin in the recrd with regard t risk, fr instance, the results frm a validated screening tl are dcumented as bth lw AND mderate/high risk, select Value 2 indicating the highest risk. Cgnitin refers t mental activities assciated with thinking, learning, and memry. Cgnitive impairment fr the purpses f this measure set is related t dcumentatin that the patient cannt be screened fr alchl use due t the impairment (e.g., cmatse, btunded, cnfused, memry lss) within the first day f admissin (by end f Day 1). If there is dcumentatin that the patient has temprary cgnitive impairment due t acute substance use (e.g., verdse r acute intxicatin), Value 7 cannt be selected. If there is dcumentatin within the first day f admissin (by end f Day 1) that the patient was psychtic, symptms f psychsis, e.g., hallucinating, nn-cmmunicative, catatnic, etc., must als be dcumented fr the patient t be cnsidered cgnitively impaired. If there is dcumentatin that the patient was intubated n the day f admissin (Day 0) and remains intubated thrugh the entire first day (Day 1), select allwable Value 7 as the patient is unable t answer. If there is dcumentatin t rule ut a cnditin/diagnsis related t cgnitive impairment, Value 7 cannt be selected unless there is dcumentatin f symptms. Examples: Patient actively hallucinating, rule ut psychsis. (Select Value 7 ). Rule ut psychsis. (Cannt select Value 7 ). If there is dcumentatin within the first day f admissin (by end f Day 1) f any f the examples belw, select Value 7 regardless f cnflicting dcumentatin. Examples f cgnitive impairment include: Altered Level f Cnsciusness (LOC) Altered Mental Status Cgnitive impairment Cgnitively impaired Cnfused Dementia Memry lss Mentally handicapped Obtunded Psychtic/psychsis with dcumented symptms Dcumentatin f cgnitive impairment verrides dcumentatin f an alchl use screen and therefre wuld nt be cnsidered "cnflicting dcumentatin." Even if the family r thers tell staff the patient uses alchl, the patient culd nt be apprpriately screened and subsequently cunseled due t cgnitive impairment. Select Value 7. Specificatins Manual fr Hspital Inpatient Quality Measures Page 6

8 Bedside Cardivascular Ultrasund Date Ratinale: The Bedside Cardivascular Ultrasund Date data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Bedside Cardivascular Ultrasund Date Bedside Cardivascular Ultrasund Perfrmed Ratinale: The Bedside Cardivascular Ultrasund Perfrmed data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Bedside Cardivascular Ultrasund Perfrmed Bedside Cardivascular Ultrasund Time Ratinale: The Bedside Cardivascular Ultrasund Time data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Bedside Cardivascular Ultrasund Time Bld Culture Cllectin Ratinale: The Bld Culture Cllectin data element is being updated t prvide additinal guidance. Suggested Data Cllectin Questin Change frm: Was a bld culture cllected in the time windw 48 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis? T: Was a bld culture cllected in the apprpriate time windw? Allwable Values Change frm: 1 (Yes) A bld culture was cllected in the time windw 48 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis. 2 (N) A bld culture was nt cllected in the time windw 48 hurs prir t and 3 hurs fllwing the presentatin f severe sepsis r unable t determine. Specificatins Manual fr Hspital Inpatient Quality Measures Page 7

9 T: 1 (Yes) A bld culture was cllected in the apprpriate time windw. 2 (N) A bld culture was nt cllected in the apprpriate time windw r unable t determine. Ntes fr Abstractin Change t: If a patient des nt receive an IV r IO antibitic within the 24 hurs befre the presentatin f severe sepsis, the apprpriate time windw is: 24 hurs prir t Severe Sepsis Present Date and Time thrugh 3 hurs fllwing Severe Sepsis Present Date and Time. If a patient des receive an IV r IO antibitic within the 24 hurs befre the presentatin f severe sepsis, the apprpriate time windw is: 24 hurs prir t the administratin f the antibitic thrugh 3 hurs fllwing Severe Sepsis Present Date and Time. Use dcumentatin specifying a bld culture was actually drawn r cllected. D nt use Labs Drawn r similar dcumentatin, as it is nt specific t bld culture. If a bld culture is rdered and there is an attempt t cllect it, but the attempt results in failure t cllect the specimen (t dehydrated t get a vein) r the specimen was cntaminated during r after the draw, select Value 1. If there is supprtive dcumentatin that a bld culture was cllected in the apprpriate time windw and it is the earliest mentin f a bld culture, this date and time can be used, e.g., BC sent t lab, bld culture received time. Select Value 1. D nt use physician rders t determine a bld culture was cllected, as they d nt demnstrate cllectin f the bld culture. Suggested Data Surces Change sixth bullet t: Physician/APN/PA Prgress Ntes Bld Culture Cllectin Date Ratinale: The Bld Culture Cllectin Date data element is being updated t prvide additinal guidance. Definitin Change t: The date n which a bld culture was cllected within the apprpriate time windw. Suggested Data Cllectin Questin Change frm: What was the date n which a bld culture was cllected in the time windw 48 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis? T: What date was the bld culture cllected n? Specificatins Manual fr Hspital Inpatient Quality Measures Page 8

10 Ntes fr Abstractin Change t: Refer t the Bld Culture Cllectin data element fr the apprpriate time windw t abstract this data element. Use dcumentatin specifying a bld culture was actually drawn r cllected. D nt use Labs Drawn r similar dcumentatin, as it is nt specific t the bld culture. If there is supprtive dcumentatin that a bld culture was cllected in the apprpriate time windw and it is the earliest mentin f a bld culture, this date can be used, e.g., BC sent t lab, bld culture received time. D nt use physician rders t determine that a bld culture was cllected, as they d nt demnstrate cllectin f the bld culture. In the event there is a failure t cllect the bld culture specimen (t dehydrated t get a vein) r the specimen was cntaminated during r after the draw, abstract the date at which the unsuccessful attempt was carried ut. Stp abstracting 3 hurs after the presentatin f severe sepsis. If multiple bld cultures were drawn r attempted, abstract the earliest bld culture drawn r attempted in the apprpriate time windw. Suggested Data Surces Add new bullet pint: Physician/APN/PA Prgress Ntes Bld Culture Cllectin Time Ratinale: The Bld Culture Cllectin Time data element is being updated t prvide additinal guidance. Definitin Change t: The time at which a bld culture was cllected within the apprpriate time windw. Suggested Data Cllectin Questin Change frm: What was the time at which a bld culture was cllected in the time windw 48 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis? T: What time was the bld culture cllected? Ntes fr Abstractin Change t: Please refer t the Bld Culture Cllectin data element fr the apprpriate time windw t abstract this data element. Use dcumentatin specifying a bld culture was actually drawn r cllected. D nt use Labs Drawn r similar dcumentatin, as it is nt specific t the bld culture. If there is supprtive dcumentatin that a bld culture was cllected in the apprpriate time windw and it is the earliest mentin f a bld culture, this time can be used, e.g., BC sent t lab, bld culture received time. Specificatins Manual fr Hspital Inpatient Quality Measures Page 9

11 D nt use physician rders t determine that a bld culture was cllected, as they d nt demnstrate cllectin f the bld culture. In the event there is a failure t cllect the bld culture specimen (t dehydrated t get a vein) r the specimen was cntaminated during r after the draw, please abstract the time at which the unsuccessful attempt was carried ut. Stp abstracting 3 hurs after the presentatin f severe sepsis. If multiple bld cultures were drawn r attempted, abstract the earliest bld culture drawn r attempted in the apprpriate time windw. Suggested Data Surces Add new bullet pint: Physician/APN/PA Prgress Ntes Brad Spectrum r Other Antibitic Administratin Selectin Ratinale: The Brad Spectrum r Other Antibitic Administratin Selectin data element is being updated t prvide additinal guidance. Ntes fr Abstractin Change t: Only IV antibitic(s) administered within 3 hurs after the Severe Sepsis Presentatin Time are acceptable. EXCEPTION: If there is dcumentatin indicating IV access culd nt be established, antibitics administered via intramuscular (IM) r intrasseus (IO) started within 3 hurs after the Severe Sepsis Presentatin Time are acceptable t select Value 1. Antibitic administratin infrmatin shuld nly be abstracted frm dcumentatin that demnstrates actual administratin within the apprpriate timeframe. If there is ne antibitic started within 3 hurs after presentatin f severe sepsis that is n the mntherapy table in Appendix C, Table 5.0, chse Value 1. If the administered antibitics were NOT n Table 5.0, determine if the antibitics are n Table 5.1 in Appendix C. Determine the class the administered antibitics belng t, based n the class name in the shaded rw abve the antibitic names. Next, refer t the fllwing Cmbinatin Antibitic Therapy Table t determine if an antibitic frm a class in bth Clumn A and Clumn B were given. There must be at least ne frm a class in clumn A and at least ne frm a class in clumn B administered t select Value 1. Review the chart t see that bth drugs were started within 3 hurs f severe sepsis presentatin and if s, chse Value 1. If bth drugs were nt started within 3 hurs, chse Value 2. Example: Severe Sepsis Presentatin Time 1200 Ciprflxacin initiated at 1230 Vancmycin initiated at 1330 Cmbinatin Antibitic Therapy Table: Specificatins Manual fr Hspital Inpatient Quality Measures Page 10

12 Ciprflxacin is in clumn A Vancmycin is in clumn B Bth antibitics were initiated within 3 hurs f the Severe Sepsis Presentatin Time, therefre Value 1 shuld be selected. Cmbinatin Antibitic Therapy Table Clumn A Clumn B Aminglycsides OR Aztrenam OR Ciprflxacin + Cephalsprins (1st and 2nd Generatin) OR Clindamycin IV OR Daptmycin OR Glycpeptides OR Linezlid OR Macrlides OR Penicillins If IV antibitic(s) frm Table 5.0 r an apprpriate cmbinatin f IV antibitics frm Table 5.1 are nt started within the 3 hurs fllwing presentatin f severe sepsis, and the fllwing cnditins are met, chse value "1." There is Physician/APN/PA dcumentatin referencing the results f a culture frm within 5 days prir t the antibitic start time. The dcumentatin must: Identify the date f the culture results (must be within 5 days prir t the antibitic start time). Identify the suspected causative rganism frm the culture result and its antibitic susceptibility. The IV antibitic(s) identified as apprpriate per the physician/apn/pa dcumentatin is started within 3 hurs fllwing the presentatin f severe sepsis. Examples: Acceptable physician/apn/pa dcumentatin: Urine culture results frm 9/10/17 shw entercccus, sensitive t vancmycin. The patient has severe sepsis with criteria met n 9/15/17 at 15:00 and the nly antibitic started is IV vancmycin at 15:30. If the patient has C. difficile, and IV antibitic(s) frm Table 5.0 r an apprpriate cmbinatin f IV antibitics frm Table 5.1 are nt started within the 3 hurs fllwing presentatin f severe sepsis, and the fllwing cnditins are met, chse value "1." There is physician/apn/pa dcumentatin within 24 hurs prir t the antibitic start time identifying the presence f C. difficile. Any ne f the treatments belw is initiated within 3 hurs fllwing severe sepsis presentatin: Oral vancmycin with r withut ral r IV metrnidazle (Flagyl) Rectal vancmycin with r withut IV metrnidazle (Flagyl) IV metrnidazle (Flagyl) mntherapy Suggested Data Surces Change tenth bullet t: Physician/APN/PA prgress ntes Specificatins Manual fr Hspital Inpatient Quality Measures Page 11

13 Capillary Refill Examinatin Date Ratinale: The data element Capillary Refill Examinatin Date is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Capillary Refill Examinatin Date Capillary Refill Examinatin Perfrmed Ratinale: The data element Capillary Refill Examinatin Perfrmed is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Capillary Refill Examinatin Perfrmed Capillary Refill Examinatin Time Ratinale: The data element Capillary Refill Examinatin Time is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Capillary Refill Examinatin Time Cardipulmnary Evaluatin Date Ratinale: The Cardipulmnary Evaluatin Date data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Cardipulmnary Evaluatin Date Cardipulmnary Evaluatin Perfrmed Ratinale: The Cardipulmnary Evaluatin Perfrmed data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Cardipulmnary Evaluatin Perfrmed Specificatins Manual fr Hspital Inpatient Quality Measures Page 12

14 Cardipulmnary Evaluatin Time Ratinale: The Cardipulmnary Evaluatin Time data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Cardipulmnary Evaluatin Time Central Venus Oxygen Measurement Ratinale: The Central Venus Oxygen Measurement data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Oxygen Measurement Central Venus Oxygen Measurement Date Ratinale: The Central Venus Oxygen Measurement Date data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Oxygen Measurement Date Central Venus Oxygen Measurement Time Ratinale: The Central Venus Oxygen Measurement Time data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Oxygen Measurement Time Central Venus Pressure Measurement Ratinale: The Central Venus Pressure Measurement data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Pressure Measurement Specificatins Manual fr Hspital Inpatient Quality Measures Page 13

15 Central Venus Pressure Measurement Date Ratinale: The Central Venus Pressure Measurement Date data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Pressure Measurement Date Central Venus Pressure Measurement Time Ratinale: The Central Venus Pressure Measurement Time data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Central Venus Pressure Measurement Time Crystallid Fluid Administratin Ratinale: The Ntes fr Abstractin were updated t prvide clarificatin t the abstractr. Ntes fr Abstractin Add new furth bullet pint: Crystallid fluids r balanced crystallid fluids that are given t dilute medicatins are acceptable t cunt twards the target rdered vlume. Add new sub-bullet pint under tenth bullet pint: Rund the vlume f IV fluid (ml) t the nearest whle number. Remve: Use the weight dcumented clsest t and prir t the rder fr crystallid fluids. If a weight is nt dcumented prir t the crystallid fluid rder, use the weight recrded clsest t and after the crystallid fluid rder. Use the patient s actual weight. Use estimated weight nly if actual weight is nt available t determine the vlume f crystallid fluids the patient shuld receive. D nt use ideal weight unless indicated by the physician/apn/pa. Add new eleventh, twelfth, and thirteenth bullet pints: Use the actual r estimated weight dcumented clsest t and prir t the rder fr crystallid fluids. If an actual r estimated weight is nt dcumented prir t the crystallid fluid rder, use the actual r estimated weight recrded clsest t and after the crystallid fluid rder. If a weight is dcumented in a crystallid fluid rder, it shuld be used t determine the target rdered vlume. Specificatins Manual fr Hspital Inpatient Quality Measures Page 14

16 Directive fr Cmfrt Care r Palliative Care, Septic Shck Directive fr Cmfrt Care r Palliative Care, Severe Sepsis Ratinale: The Directive fr Cmfrt Care, Septic Shck and Directive fr Cmfrt Care, Severe Sepsis data elements are being updated t prvide an additinal inclusin term. Inclusin Guidelines fr Abstractin Add new bullet pint: Palliative Cnsult Discharge Time Ratinale: The Discharge Time data element is being updated t prvide additinal guidance. Definitin Change t: The time the patient was discharged frm acute care, left against medical advice (AMA), r expired during this stay. Discharge Time Ratinale: The Discharge Time data element is being updated t address bth expired and discharged patients. Ntes fr Abstractin Add new first bullet with sub-bullets: Abstract the earliest dcumented time f the fllwing: Discharge frm acute inpatient care Left against medical advice (AMA) Expired Change secnd bullet t: If the time the patient was discharged frm acute inpatient care, left AMA, r expired is unable t be determined frm medical recrd dcumentatin, enter UTD. Change sixth bullet t: If the patient was discharged frm acute inpatient care, left AMA, r transferred ut t anther facility, use the time the patient actually left, nt the time the rder was written. Change seventh bullet t: If there are multiple times dcumented when the patient was discharged frm acute inpatient care r left AMA, use the earliest time. Fluid Challenge Date Ratinale: The data element Fluid Challenge Date is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Specificatins Manual fr Hspital Inpatient Quality Measures Page 15

17 Remve in Index and Data Dictinary in its entirety: Fluid Challenge Date Fluid Challenge Perfrmed Ratinale: The data element Fluid Challenge Perfrmed is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Fluid Challenge Perfrmed Fluid Challenge Time Ratinale: The data element Fluid Challenge Time is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Fluid Challenge Time Initial Hyptensin Ratinale: The data element Initial Hyptensin is being updated t prvide additinal guidance. Ntes fr Abstractin Change eighth bullet t: If within 24 hurs f the Severe Sepsis Presentatin Time there is physician/apn/pa r nursing dcumentatin indicating a hyptensive reading is invalid, errneus r questinable, disregard that reading when determining the presence f initial hyptensin. Initial Lactate Level Cllectin Ratinale: The data element Initial Lactate Level Cllectin is being updated t prvide additinal guidance. Ntes fr Abstractin Change secnd bullet t: If within 24 hurs f the Severe Sepsis Presentatin Time there is physician/apn/pa r nursing dcumentatin that a lactate value is invalid, errneus r questinable, disregard that value. Specificatins Manual fr Hspital Inpatient Quality Measures Page 16

18 New Data Elements Initial Hyptensin Date Initial Hyptensin Time Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Date Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Time Ratinale: New data elements are being added t prvide guidance fr abstractin. Index Add new data elements: Initial Hyptensin Date t the left clumn, the page number t the middle clumn and SEP-1 in the Cllected Fr clumn. Initial Hyptensin Time t the left clumn, the page number t the middle clumn and SEP-1 in the Cllected Fr clumn. Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed in left clumn, the page number in the middle clumn and "SEP-1" in the Cllected fr clumn. Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Date t the left clumn, the page number t the middle clumn and SEP-1 t the Cllected Fr clumn. Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Time t the left clumn, the page number t the middle clumn and SEP-1 t the Cllected Fr clumn. Alphabetical Data Dictinary Add new data element pages: Initial Hyptensin Date Initial Hyptensin Time Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Date Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed Time Passive Leg Raise Exam Date Ratinale: The Passive Leg Raise Exam Date data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Passive Leg Raise Exam Date Passive Leg Raise Exam Perfrmed Ratinale: The Passive Leg Raise Exam Perfrmed data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Specificatins Manual fr Hspital Inpatient Quality Measures Page 17

19 Remve in Index and Data Dictinary in its entirety: Passive Leg Raise Exam Perfrmed Passive Leg Raise Exam Time Ratinale: The Passive Leg Raise Exam Time data element was remved because it was incrprated int Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Passive Leg Raise Exam Time Peripheral Pulse Evaluatin Date Ratinale: The data element Peripheral Pulse Evaluatin Date is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Peripheral Pulse Evaluatin Date Peripheral Pulse Evaluatin Perfrmed Ratinale: The data element Peripheral Pulse Evaluatin Perfrmed is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Peripheral Pulse Evaluatin Perfrmed Peripheral Pulse Evaluatin Time Ratinale: The data element Peripheral Pulse Evaluatin Time is being deleted as it is being incrprated int the Repeat Vlume Status and Tissue Perfusin Assessment Perfrmed data element. Remve in Index and Data Dictinary in its entirety: Peripheral Pulse Evaluatin Time Specificatins Manual fr Hspital Inpatient Quality Measures Page 18

20 Persistent Hyptensin Ratinale: The data element Persistent Hyptensin is being updated t prvide additinal guidance. Ntes fr Abstractin Change secnd sub-bullet under secnd bullet t: If there are mre than tw bld pressures dcumented, refer t the last tw cnsecutive bld pressures within the hur: Change last bullet t: If within 24 hurs f the Severe Sepsis Presentatin Time there is physician/apn/pa r nursing dcumentatin indicating a hyptensive reading is errneus r questining the validity f a hyptensive reading, disregard that reading fr determining the presence f persistent r new nset f hyptensin. Prescriptin fr Tbacc Cessatin Medicatin Ratinale: The Ntes fr Abstractin were updated t clarify hw t abstract patient refusal f tbacc cessatin medicatin. Ntes fr Abstractin Add furth bullet: If NRT r a prescribed FDA-apprved tbacc cessatin medicatin is listed as a discharge medicatin but there is als dcumentatin f refusal by the patient at discharge, select Value 2. Reasn fr N Tbacc Cessatin Medicatin at Discharge Ratinale: Data element is being updated t capture the measure exclusin fr pregnant patients. Definitin Add new third bullet: Patient is pregnant Ntes fr Abstractin Change first bullet t: Reasns (ther than pregnancy) fr nt prescribing FDA-apprved tbacc cessatin medicatins must be dcumented by a physician/apn/pa r pharmacist. Add new secnd bullet: If there is any dcumentatin in the medical recrd indicating the patient is pregnant, select Yes. Specificatins Manual fr Hspital Inpatient Quality Measures Page 19

21 Reasn fr N Tbacc Cessatin Medicatin During the Hspital Stay Ratinale: Data element is being updated t capture the measure exclusin fr pregnant patients. Definitin Add new third bullet: Patient is pregnant Ntes fr Abstractin Change first bullet t: Reasns (ther than pregnancy) fr nt prescribing FDA-apprved tbacc cessatin medicatins must be dcumented by a physician/apn/pa r pharmacist. Add new secnd bullet: If there is any dcumentatin in the medical recrd indicating the patient is pregnant, select Yes. Reasn fr N Administratin f VTE Prphylaxis Ratinale: The Definitin, Suggested Data Cllectin Questin, Allwable Values, Ntes fr Abstractin, and Inclusin and Exclusin Guidelines fr Abstractin were updated t clarify acceptable dcumentatin f reasns fr nt administering VTE prphylaxis. Definitin Change t: Physician/APN/PA r pharmacist dcumentatin why mechanical AND pharmaclgical VTE prphylaxis were nt administered n the day(s) between arrival and the day befre the VTE Diagnstic Test rder date. Bth mechanical and pharmaclgical prphylaxis must be addressed. Suggested Data Cllectin Questin Change frm: Is there physician/apn/pa r pharmacist dcumentatin why VTE prphylaxis was nt administered n the days between arrival and the VTE Diagnstic Test perfrmed? T: Is there physician/apn/pa r pharmacist dcumentatin why VTE prphylaxis was nt administered n the day(s) between arrival and the day befre the VTE Diagnstic Test rder date? Allwable Values Change frm: Y (Yes) There is physician/apn/pa r pharmacist dcumentatin why mechanical AND pharmaclgical VTE prphylaxis were nt administered n the days between arrival and the VTE Diagnstic Test perfrmed. Specificatins Manual fr Hspital Inpatient Quality Measures Page 20

22 N (N) T: Y (Yes) N (N) There is n physician/apn/pa r pharmacist dcumentatin why mechanical AND pharmaclgical VTE prphylaxis were nt administered n the days between arrival and the VTE Diagnstic Test perfrmed, r unable t determine frm medical recrd dcumentatin. There is physician/apn/pa r pharmacist dcumentatin why mechanical AND pharmaclgical VTE prphylaxis were nt administered n the day(s) between arrival and the day befre the VTE Diagnstic Test rder date. There is n physician/apn/pa r pharmacist dcumentatin why mechanical AND pharmaclgical VTE prphylaxis were nt administered n the day(s) between arrival and the day befre the VTE Diagnstic Test rder date, r unable t determine frm medical recrd dcumentatin. Ntes fr Abstractin Change t: T select Yes fr this data element, dcumentatin f a reasn fr nt administering mechanical AND pharmaclgical VTE prphylaxis must be dated between hspital arrival and the day befre the VTE Diagnstic Test rder date. Refer t the data element VTE Diagnstic Test fr a list f acceptable tests. Reasns fr nt prescribing VTE prphylaxis must be dcumented by a physician/apn/pa r pharmacist. EXCEPTIONS: Patient/family refusal may be dcumented by a nurse, but shuld be dcumented within the same timeframe as the reasn fr n VTE prphylaxis. Patient/family refusal f any frm f prphylaxis is acceptable t select Yes. Fr example, patient refused heparin, select Yes. A validated risk assessment may be dcumented by a nurse, but shuld be dcumented within the same timeframe as the reasn fr n administratin f VTE prphylaxis. Fr patients receiving anticagulant therapy, including cntinuus IV heparin infusin, the day befre the VTE diagnstic test rder date, select Yes. Disregard IV heparin administered t flush/maintain patency f a line r dialysis equipment and IV heparin administered during an interventinal prcedure, e.g., cardiac cath. If reasns are nt mentined in the cntext f VTE prphylaxis, d nt make inferences (e.g., d nt assume that VTE Prphylaxis was nt administered because f a bleeding disrder unless dcumentatin explicitly states s). Example: Physician/APN/PA dcumentatin f bleeding risk, review the chart fr dcumentatin abut reasns fr n mechanical AND n pharmaclgical VTE prphylaxis. If the VTE Diagnstic Test was perfrmed the day f r the day after arrival, select Yes. Dcumentatin that a frmal risk assessment was administered AND the results indicated that there was n risk r lw risk fr VTE is acceptable as a reasn fr nt administering VTE prphylaxis. Specificatins Manual fr Hspital Inpatient Quality Measures Page 21

23 If a cpy f the validated risk assessment is included in the medical recrd alng with the results, select Yes. Dcumentatin f a lw risk scre withut a cpy f the validated risk assessment is acceptable, if the validated risk assessment tl used is mentined in the nte. See Inclusin Guidelines fr Abstractin. Dcumentatin f lw risk r n risk withut mentin f a scre and the validated risk assessment tl, select N. If tw physicians/apn/pa r pharmacist dcument cnflicting r questinable needs fr prphylaxis, select N. Inclusin Guidelines fr Abstractin Change t: Explicit dcumentatin that the patient des nt need VTE prphylaxis ALL INCLUSIVE VALIDATED RISK ASSESSMENTS: Caprini DVT Risk Assessment Padua Predictin Scre Internatinal Medical Preventin Registry n Venus Thrmbemblism (IMPROVE) LOW RISK SCORES: Caprini scre f 0 (zer) n need fr prphylaxis IMPROVE scre f 0 (zer) r 1 (ne); r a prbability f less than 1.5% Padua scre f less than 4 (0-3) Refer t Appendix H, Table 2.7 Anticagulatin Therapy Exclusin Guidelines fr Abstractin Change t: Risk Assessment tls ther than Caprini, Padua, and IMPROVE Septic Shck Present Ratinale: The Septic Shck Present data element is being updated t prvide additinal guidance. Ntes fr Abstractin Change t: Presence f Septic Shck may be identified based upn clinical criteria r physician/apn/pa dcumentatin f Septic Shck. In rder t establish the presence f Septic Shck by clinical criteria, ne f fllwing tw criteria (a r b) must be met: a. Severe Sepsis Present AND Persistent Hyptensin in the hur after the cnclusin f the target rdered vlume f Crystallid Fluid Administratin, evidenced by tw cnsecutive dcumented recrdings f: systlic bld pressure (SBP) <90, r mean arterial pressure <65 r Specificatins Manual fr Hspital Inpatient Quality Measures Page 22

24 a decrease in systlic bld pressure by >40 mmhg. Physician/APN/PA dcumentatin must be present in the medical recrd indicating a >40 mmhg decrease in SBP has ccurred and is related t infectin, Severe Sepsis r Septic Shck and nt ther causes. b. Severe Sepsis Present AND Tissue hypperfusin evidenced by Initial Lactate Level Result is >=4 mml/l Fr evaluatin f bld pressure parameters t establish whether r nt hyptensin persists after crystallid fluid administratin, begin abstracting at the time that crystallid fluid administratin cncludes (refer t the Persistent Hyptensin data element); abstract fr the time perid that fllws fr the next hur nly. Chse Value 1 if hyptensin (systlic bld pressure <90, r mean arterial pressure <65 r a decrease in systlic bld pressure by >40 mmhg) was present in the hur after crystallid fluid administratin fr tw r mre cnsecutive readings. Use the time vital signs were taken r btained. If time taken r btained is nt available, use recrded r dcumented time. If there is physician/apn/pa dcumentatin prir t r within 24 hurs after Severe Sepsis Presentatin Time indicating hyptensin (SBP <90 mmhg r MAP <65 mmhg) is due t the fllwing, it shuld nt be used. Inferences shuld nt be made. It is required that the same physician/apn/pa dcumentatin must als include either the abnrmal value r reference the abnrmal value. Nrmal fr that patient Is due t a chrnic cnditin Is due t a medicatin If there is physician/apn/pa dcumentatin prir t r within 24 hurs after Severe Sepsis Presentatin Time indicating hyptensin (SBP <90 mmhg r MAP <65 mmhg) is due t the fllwing, the criteria value shuld be used. Acute cnditin Acute injury n a chrnic cnditin Example: Hyptensin due t acute exacerbatin n chrnic heart failure. If there is physician/apn/pa dcumentatin prir t r within 24 hurs f Severe Sepsis Presentatin Time indicating the acute cnditin is due t a nn-infectius surce/prcess, it shuld nt be used (Refer t Severe Sepsis Present t determine if a cnditin is an infectin). Example: Hyptensin due t acute bld lss secndary t trauma. If within 24 hurs after the Severe Sepsis Presentatin Time there is physician/apn/pa r nursing dcumentatin that a hyptensive reading is invalid, errneus r questinable, disregard that reading when determining the presence f Septic Shck. If Septic Shck presentatin is mre than six hurs after Severe Sepsis Presentatin Time, chse Value 2. Disregard dcumentatin f Septic Shck in a discharge nte r discharge summary. If criteria fr Septic Shck are nt met, but there is physician/apn/pa dcumentatin f Septic Shck, chse Value 1. Specificatins Manual fr Hspital Inpatient Quality Measures Page 23

25 The title r heading f an rder set, prtcl, checklist, alert, screening tl, etc. reflecting an infectin, SIRS, Sepsis, Severe Sepsis, r Septic Shck shuld nt be used t meet criteria. Dcumentatin f a criterin r Septic Shck within an rder set, prtcl, checklist, alert, screening tl, etc., may be used if the fllwing is true: The dcumentatin r value and recrded date and time is present and is the earliest date and time recrded fr the criteria. Chse Value 2 if within 6 hurs after dcumentatin meeting clinical criteria r physician/apn/pa dcumentatin f Septic Shck there is additinal physician/apn/pa dcumentatin indicating: Patient is nt septic Patient des nt have Sepsis, Severe Sepsis, Septic Shck Septic Shck is due t a viral, fungal r parasitic infectin Fr dcumentatin f Septic Shck accmpanied by a qualifier, the table belw shuld be used. Dcumentatin cntaining a psitive qualifier shuld be used t meet criteria, dcumentatin cntaining a negative qualifier shuld nt be used t meet criteria. Psitive Qualifiers Pssible Rule ut (r/) Suspected Likely Prbable Differential Diagnsis Suspicius fr Cncern fr Negative Qualifiers Impending Unlikely Dubt Risk fr Ruled ut Evlving Questinable Septic Shck Presentatin Date Ratinale: The Septic Shck Presentatin Date data element is being updated t prvide additinal guidance. Ntes fr Abstractin Change seventh bullet t: If septic shck is in a physician/apn/pa nte withut a specific date dcumented within the nte r dcumented using the acrnym POA, the fllwing apply: If it is the nly dcumentatin f Septic Shck in the nte, use the date the nte was started r pened. If Septic Shck is dcumented multiple times within the same nte, use the earliest specified date. Septic Shck Presentatin Time Ratinale: The Septic Shck Presentatin Date data element is being updated t prvide additinal guidance. Specificatins Manual fr Hspital Inpatient Quality Measures Page 24

26 Ntes fr Abstractin Change seventh bullet t: If septic shck is in a physician/apn/pa nte withut a specific time dcumented within the nte r dcumented using the acrnym POA, the fllwing applies: If it is the nly dcumentatin f Septic Shck in the nte, use the time the nte was started r pened. If Septic Shck is dcumented multiple times within the same nte, use the earliest specified time. Severe Sepsis Present Ratinale: The Severe Sepsis Present data element is being updated t prvide additinal guidance. Ntes fr Abstractin Change t: Presence f Severe Sepsis may be identified based upn clinical criteria r physician/apn/pa dcumentatin f Severe Sepsis. In rder t establish the presence f Severe Sepsis by clinical criteria, all three clinical criteria (a, b, and c) must be met within 6 hurs f each ther. The three clinical criteria d nt need t be dcumented in any particular rder. a. Dcumentatin f an infectin. Physician/APN/PA r nursing dcumentatin referencing the presence f an infectin is acceptable. Physician/APN/PA, nursing, r pharmacist dcumentatin indicating a patient is being treated with an antibitic fr an infectin and that antibitic is dcumented as administered within 6 hurs f criteria b r c is acceptable (e.g., Levaquin is dcumented in MAR fr pneumnia and nursing dcumentatin indicates a dse was given within 6 hurs f criteria b and c, pharmacy nte that patient is n vancmycin fr pneumnia). If dcumentatin f an infectin is in a physician/apn/pa, nursing, r pharmacist nte withut a specific date and time r dcumented using the acrnym POA, use the date and time the nte was started r pened. If the nte states an infectin was present n arrival, use the earliest dcumented arrival date and time. If the nte states an infectin was present n admissin, use the earliest dcumented hspital bservatin/inpatient admissin date and time. If an infectin is dcumented and within 6 hurs fllwing the initial dcumentatin f the infectin, there is additinal physician/apn/pa dcumentatin indicating the infectin is nt present, disregard the initial dcumentatin f the infectin. Examples: ED physician/apn/pa dcuments rule ut UTI and pneumnia at 05:00. At 10:00 hspitalist dcuments n Specificatins Manual fr Hspital Inpatient Quality Measures Page 25

27 infectin present. Disregard ED physician/apn/pa dcumentatin f rule ut UTI and pneumnia. ED physician/apn/pa dcuments suspected UTI and pneumnia at 09:00. At 12:30 infectius disease APN dcuments n UTI. Disregard the initial dcumentatin f suspected UTI. Dcumentatin f pneumnia is still valid t use fr an infectin. Dcumentatin f an infectin in an active prblem list is acceptable if there is infrmatin in the medical recrd supprting the infectin is current. If a cnditin dcumented in the medical recrd des nt include the wrd infectin, r is nt in the Inclusin Guidelines fr Abstractin infectin list, cnsulting ther medical resurces (such as a medical dictinary) t identify whether r nt the cnditin is an infectin r is caused by an infectin is acceptable. i. If the ther medical resurce indicates the cnditin is an infectin r is caused by an infectin, it may be used t meet the suspected infectin criteria. ii. If the ther medical resurce indicates the cnditin is NOT an infectin and NOT caused by an infectin, it may NOT be used t meet the suspected infectin criteria. iii. If the ther medical resurce indicates the cnditin may r may nt be an infectin, r may be caused by an infectin r may be caused by smething ther than an infectin, there must be additinal dcumentatin in the medical recrd supprting the cnditin is an infectin (e.g., antibitic rdered fr the cnditin) t be used t meet the suspected infectin criteria. If an antibitic is rdered fr a cnditin that may be inflammatin r a sign r symptm f an infectin this may be cnsidered dcumentatin f an infectin (e.g., ceftriaxne rdered fr clitis, Zsyn g IV q6hr fr cugh). Exclude dcumentatin f viral, fungal, r parasitic infectins. b. Tw r mre manifestatins f systemic infectin accrding t the Systemic Inflammatry Respnse Syndrme (SIRS) criteria, which are: Temperature >38.3 C r <36.0 C (>100.9 F r <96.8 F) Heart rate (pulse) >90 Respiratin >20 per minute White bld cell cunt >12,000 r <4,000 r >10% bands c. Organ dysfunctin, evidenced by any ne f the fllwing: Systlic bld pressure (SBP) <90 mmhg r mean arterial pressure <65 mmhg. If there is physician/apn/pa dcumentatin prir t r within 24 hurs after Severe Sepsis Presentatin Time indicating hyptensin r lw bld pressure (SBP <90 mmhg r MAP <65 mmhg) is due t the fllwing, the criteria value shuld be used. Acute cnditin Acute injury n chrnic cnditin Specificatins Manual fr Hspital Inpatient Quality Measures Page 26

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