Hospital Outpatient Quality Reporting Specifications Manual Version 6.0b Encounter Dates 1/1/13 12/31/2013

Transcription

1 Hospital Outpatient Quality Reporting Specifications Manual Version 6.0b Encounter Dates 1/1/13 12/31/2013 Wanda Marvel, R.N., M.S. Vice President of Performance Measurement Missouri Hospital Association

2 Outpatient Measures - MBQIP

3 Outpatient Measures - MBQIP Acute Myocardial Infarction (AMI) OP-1 Median Time to Fibrinolysis OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4 Aspirin at Arrival OP-5 Median Time to ECG Chest Pain (CP) OP-4 Aspirin at Arrival OP-5 Median Time to ECG

4 Outpatient Measures Surgery Surgery OP-6 Timing of Antibiotic Prophylaxis OP-7 Prophylactic Antibiotic Selection for Surgical Patients

5 Outpatient Care CMS considers these measures to be important in the care of Medicare Beneficiaries ED measures developed for CAHs and small rural hospitals

6 Acute Myocardial Infarction (AMI)

7 AMI Population of the OP-1 - OP-5 AMI measures is identified using 5 data elements E/M Code may be problematic if CAHs not coding for this Discharge Code Outpatient Encounter Date Birthdate ICD-9 Principal Diagnosis Code

8 AMI Population OP-1 through OP-5 AMI ED with an E/M Code on Appendix A OP Table 1.0 Discharged / transferred to a short-term general hospital for inpatient care or to a Federal healthcare facility and Patient Age >= 18 years, and An ICD-9 Principal Diagnosis Code for AMI defined in Appendix A, OP Table 1.1

9 Identification Population OP Problematic

10 Issues Billing codes used to ID pop CAHs billing not identical to acute care billing How billed decides pop not location of services or service type Surgery codes case could have procedure in radiology and not be treated as a surgery case Generally means case does not pass scoring

11 Clinics - Acute Care Clinic services (NOT RURAL HEALTH CLINICS) can be included since pop is ID by billing codes Clinic bills under hospital outpatient services and not as a free standing clinic puts cases into the hospital OP population

12 Population Size CMS not validating population counts against claims due to the issues in identifying population CMS is validating sample size based upon hospital population submitted mismatch is an automatic failed validation for acute care hospitals Claim data must be the same or less than hospital submitted population size

13 OP-1 Median Time to Fibrinolysis

14 Median Time to Fibrinolysis Continuous Variable Time from ED arrival to administration of fibrinolytic AMI patients with ST-segment elevation or LBBB on the ECG performed closest to arrival and prior to transfer

15 Median Time to Fibrinolysis Inclusions and Exclusions Included Populations ST-segment elevation or LBBB on the ECG performed closest to ED arrival, and Fibrinolytic Administration Excluded Populations Did not receive Fibrinolytic within 30 minutes and had a Reason for Delay in Fibrinolytic Therapy

16 Fibrinolytic Administration Date/Time

17 Fibrinolytic Administration Date/Time Notes If two or more different fibrinolytic administration dates/times (either different fibrinolytic episodes or corresponding with the same episode), enter the earliest date/time If patient was brought to the hospital via ambulance and fibrinolytic therapy was infusing at the time of hospital arrival, enter the date/time of arrived Exclusion Guidelines for Abstraction: Fibrinolytics given during or after a PCI

18 Fibrinolytic Administration

19 Fibrinolytic Administration Notes Fibrinolytic therapy was infusing at the time of arrival, abstract Yes In the event the patient was brought to the ED via ambulance and fibrinolytic therapy was infused during transport but was completed at the time of emergency department arrival, abstract No If the first dose of reteplase (Retavase) is given in the ambulance and the second dose is given in the emergency department, abstract Yes

20 Initial ECG Interpretation

21 Initial ECG Interpretation Inclusion Guidelines ST-segment elevation MI with any mention of location/combinations of locations (anterior, apical, basal, inferior, lateral, posterior, or combination), described as acute/evolving Q wave MI, if described as acute/evolving ST ST, ST abnormality, or ST changes consistent with injury or acute/evolving MI ST-elevation (STE) ST-elevation myocardial infarction (STEMI) ST-segment noted as.10mv ST-segment noted as 1 mm STEMI or equivalent Transmural MI, if described as acute/evolving

22 Initial ECG Interpretation LBBB Inclusion Guidelines Left bundle branch block (LBBB) Intraventricular conduction delay of LBBB type Variable LBBB

23 Exclusions ECG Interpretation Exclusion Guidelines ST-segment elevation Non Q wave MI (NQWMI) or Non ST-elevation MI (NSTEMI) ST-elevation (ST ) clearly described as confined to ONE lead Minimal, Non-diagnostic, Non-specific ST-elevation (ST, STE) ST-elevation or ST-segment noted as <.10 mv in elevation or < 1 mm ST- elevation or ST- segment noted using of one of the negative modifiers or qualifiers ST-elevation (ST ) with any mention of early repolarization, left ventricular hypertrophy (LVH), normal variant, pericarditis, or Printzmetal's variant ST abnormality, or ST changes consistent with injury or acute/evolving MI OR any of the MI Inclusion terms described using one of the negative modifiers or qualifiers ST-segment elevation, or any of the other ST-segment elevation inclusion terms, with any mention of pacemaker/pacing (unless atrial only or nonfunctioning pacemaker)

24 Exclusion LBBB ECG Interpretation Exclusion Guidelines Left bundle branch block (LBBB) Incomplete left bundle branch block (LBBB) Left bundle branch block or other left bundle branch block inclusion terms using negative modifiers or qualifiers LBBB with inclusion terms and mention of pacemaker/pacing (unless atrial only or nonfunctioning pacemaker) in one interpretation

25 Qualifiers Negative Findings Consider this list all-inclusive Qualifiers And/or (+/-; ST abnormalities consistent with ischemia and/or injury ), except when comparing only Inclusions Cannot exclude Cannot rule out Could/may/might be Could/may/might have been Could/may/might have had Could/may/might indicate Or, except when comparing only Inclusions Questionable (?) Risk of Ruled out (r d/o, r/o d) Suggestive of Suspect Suspicious Vs., except when comparing only Inclusions

26 Modifiers Negative Findings Modifiers -Consider this list all-inclusive Borderline Insignificant/not significant/no significance Minor Scant Slight Sub-clinical Subtle Trace Trivial

27 Initial ECG Interpretation

28 Initial ECG Interpretation Allowable Values Yes - ST-segment elevation or a LBBB on the interpretation of the 12-lead ECG performed closest to ED arrival No - No ST-elevation or LBBB on the interpretation of the 12-lead ECG performed closest to ED arrival, no interpretation or report available for the ECG performed closest to ED arrival or UTD

29 Initial ECG ECG interpretation definition 12-lead tracing with name/initials of the physician who reviewed the ECG signed, or typed on the report, or Physician documentation of ECG findings in another source ED note regarding initial ECG findings

30 Initial ECG Interpretation Methodology Methodology 1. Identify ECG performed closest to arrival but not more than 1 hour prior to arrival If unable to determine which ECG was performed closest to arrival, abstract No Exception: If the pre-arrival ECG and the first ECG performed after arrival at the hospital are exactly the same amount of time away from hospital arrival use the first ECG performed after hospital arrival

31 Initial ECG Interpretation Methodology Step Two 2. SIGNED tracing only Determine if the terms or phrases are Inclusions or Exclusions. Evaluate findings line by line - Do not cross reference between lines except for those Exclusions with with mention of phrasing

32 Initial ECG Interpretation Methodology Step Two Continued (LVH and ST-elevation noted on separate lines on the same ECG meets the Exclusion ST- elevation with mention of early repolarization, left ventricular hypertrophy (LVH), normal variant, pericarditis, or Printzmetal s variant Any Exclusion language abstract No for positive initial ECG regardless of other documentation No need to review further

33 Step 3 Initial ECG Interpretation 3. No signed tracing proceed to other interpretations that refer to the ECG done closest to arrival Only those terms specifically identified by physician as ECG findings AND where documentation is clear it is from the ECG performed closest to arrival should be considered in abstraction.

34 Step 3 continued Initial ECG Interpretation Do not cross reference findings between interpretations any Exclusion in any of the other interpretations, abstract No, regardless of other documentation No need to review further

35 Step 4 Initial ECG Interpretation 4. At the end of your review, if you have no Exclusions, and either the signed ECG tracing or interpretations of this ECG tracing include at least one Inclusion, abstract Yes No inclusions abstract NO

36 Notes Initial ECG Interpretation Disregard any description of an MI or STsegment that is not on either the Inclusion list or the Exclusion list Contradictory documentation within the same interpretation or between different interpretations, abstract No Inclusion terms are described using the qualifier possible, disregard - neither Inclusion nor Exclusion

37 Reason for Delay in Fibrinolytic Therapy

38 Reason Delay in Fibrinolytic Therapy Notes System reasons are not acceptable, regardless of any linkage to the delay in fibrinolysis/reperfusion Equipment-related (IV pump malfunction) Staff-related (waiting for fibrinolytic from pharmacy) Consultation with other clinician that is not clearly linked to a patient-centered reason Documentation must be made clear somewhere in the record that (1) a hold, delay, deferral, or wait in initiating fibrinolysis/reperfusion actually occurred, AND (2) that the underlying reason for that delay was non-system in nature

39 Reason Delay in Fibrinolytic Therapy EXCEPTIONS Physician documentation event within 30 minutes after arrival cardiopulmonary arrest mechanical intubation OR initial patient/family refusal of fibrinolysis/reperfusion are acceptable reasons that do NOT require documentation initiating fibrinolysis In order to be considered an automatic acceptable reason for delay, documentation it occurred within 30 minutes after arrival must be CLEAR

40 Reason Delay in Fibrinolytic Therapy Exceptions continued If unable to determine that a reason is system in nature, abstract No Reasons for delay in fibrinolytic should be collected regardless of how soon after arrival it was ultimately initiated or how minimal the delay

41 Reason Delay in Fibrinolytic Therapy Inclusion Cardiopulmonary arrest Cardiac arrest Cardiopulmonary resuscitation (CPR) Defibrillation Respiratory arrest Ventricular fibrillation (V-fib)

42 OP-2 Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

43 Fibrinolytic 30 Minutes of ED Arrival Numerator ED AMI patients whose time from ED arrival to fibrinolysis is 30 minutes or less Denominator ED AMI patients with ST-segment elevation or LBBB on ECG who received fibrinolytic therapy

44 Fibrinolytic 30 Minutes of ED Arrival Excluded Populations Patients less than 18 years of age Patients who did not receive Fibrinolytic within 30 minutes AND had a Reason for Delay in Fibrinolytic Therapy

45 OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention

46 Transfer to Another Facility Continuous Variable Time (in minutes) from emergency department arrival to transfer to another facility for acute coronary intervention

47 Transfer to Another Facility Inclusions and Exclusions Included Populations ST-segment elevation or LBBB on the ECG performed closest to ED arrival, and Transfer for Acute Coronary Intervention Excluded Populations Patients receiving Fibrinolytic Administration

48 Reason for Not Administering Fibrinolytic Therapy

49 Reason for No Fibrinolytic Allowable Values Documented contraindication/reason Contraindication or other reason documented by a physician or pharmacist for not prescribing fibrinolytic, including patient refusal Cardiogenic Shock physician documentation of cardiogenic shock No documented contraindication/reason or UTD No documentation of contraindication for not prescribing fibrinolytic therapy or UTD

50 Notes Reason for No Fibrinolytic Conflicting documentation, a positive finding (fibrinolytic allergy) should take precedence over a negative finding (no known allergy) Only use reasons or contraindications listed In situations where there is documentation that would support more than one of the allowable values, 1-3, select the lowest value

51 Inclusions Contraindications Reason for No Fibrinolytic Inclusion Guidelines Contraindications Any prior intracranial hemorrhage Known structural cerebral vascular lesion Known malignant intracranial neoplasm, Ischemic stroke within 3 months EXCEPT acute ischemic stk Suspected aortic dissection Active bleeding Significant closed head trauma or facial trauma within 3 months Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg

52 Inclusions Reason for No Fibrinolytic Inclusion Guidelines Contraindications Hx of prior ischemic stroke > 3 months, dementia, or known intracranial pathology not covered Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 Weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior expose (> 5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants prior to arrival

53 Transfer for Acute Coronary Intervention

54 Transfer Acute Coronary Intervention Allowable Values 1 Documentation patient was transferred from this facility s ED to another facility specifically for acute coronary intervention 2 Documentation patient was admitted to observation status prior to transfer 3 Documentation the patient was transferred from this facility s ED to another facility for reasons other than acute coronary intervention, or the specific reason for transfer was UTD

55 Transfer Acute Coronary Intervention Notes Abstract value 1 (transfer), documentation must include a specifically defined reason for transfer such as Percutaneous Coronary Intervention, Angioplasty, or for cardiac cath Astract value 2 (observation), there must be documentation of a physician order to admit to observation status

56 Transfer Acute Coronary Intervention Inclusion Guidelines Acute angiogram Acute cardiac intervention Acute coronary intervention Angioplasty Cath lab Cardiac catheterization Interventional cardiology Percutaneous Coronary Intervention Primary Percutaneous Coronary Intervention Primary PCI PCI

57 Acute Myocardial Infarction (AMI) & Chest Pain (CP)

58 OP-4 Aspirin at Arrival

59 Aspirin at Arrival Numerator Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain) who received aspirin within 24 hours before ED arrival or prior to transfer Denominator Emergency Department AMI or Chest Pain patients (with Probable Cardiac Chest Pain)

60 Aspirin at Arrival Inclusions and Exclusions Included Populations Discharged to a short term general hospital, or to a Federal healthcare facility, and ICD-9 Principal Dx Code for AMI in Table 1.1 or an ICD-9 Principal or Other Dx Codes for Angina, Acute Coronary Syndrome, or Chest Pain Table 1.1a with Probable Cardiac Chest Pain Excluded Populations Patients with a documented Reason for No Aspirin on Arrival

61 Aspirin Received

62 Aspirin Received Allowable Values Yes - Aspirin was received within 24 hours before emergency department arrival or administered prior to transfer No - Aspirin was not received within 24 hours before emergency department arrival or administered prior to transfer or UTD

63 Notes Aspirin Received In non-transfer cases Aspirin listed as current or home medication should be inferred as taken within 24 hours prior to Arrival Time, unless documentation suggests otherwise ASA is listed as home medication and last dose is noted as the day prior to arrival but no time, then infer aspirin was taken within 24 hours

64 Aspirin Received Aspirin noted only as received prior to arrival, without information about the exact time it was received infer that the patient took it within 24 hours prior to Arrival Time, unless documentation suggests otherwise Aspirin documented as a PRN current/home medication does not count unless documentation is clear it was taken within 24 hours prior to Arrival Time

65 Probable Cardiac Chest Pain

66 Probable Cardiac Chest Pain Allowable Values Yes - There was nurse or physician documentation the chest pain was presumed to be cardiac in origin No - There was no nurse or physician documentation the chest pain was presumed to be cardiac in origin or UTD

67 Notes Probable Cardiac Chest Pain Documentation of a differential/working dx of acute myocardial infarction select Yes Disregard documentation of inclusions/exclusions described with terms indicating the condition is not acute, such as history of If there is documentation by the nurse or physician of an exclusion term, abstract No, unless there is a working/differential diagnosis of AMI continue to abstract Yes

68 Excluded Data Sources Probable Cardiac Chest Pain EXCLUDED DATA SOURCES Chest X-Ray Reports Radiology Reports

69 Inclusions Probable Cardiac Chest Pain AMI and Chest Pain Inclusions Acute coronary syndrome Acute myocardial infarction (AMI) Angina Cardiac Cardiac Chest Pain Chest Pain Heart attack Ischemia Myocardial Infarction Unstable angina

70 Qualifiers Abstract As Positive Findings If Listed With Any Inclusion Terms Appears to have Cannot exclude Cannot rule out Consider Consistent with (c/w) Could/may/might be Could/may/might have been Diagnostic of Differential diagnosis Evidence of Indicative of Likely Could/may/might have had Could/may/might indicate Most likely Possible Probable Questionable (?) Representative of Risk of Rule(d) out (r/o) Suggestive of Suspect Suspicious Versus (vs) Working diagnosis +

71 Exclusions Probable Cardiac Chest Pain Exclusion Guidelines Atypical Chest Pain Chest Pain musculoskeletal Chest Pain qualified by a non-cardiac cause Chest wall pain Non Cardiac Chest Pain Non-specific Chest Pain Traumatic Chest Pain Trauma MVA (Motor Vehicle Accident)

72 Reason for No Aspirin on Arrival

73 Reason For No Aspirin on Arrival Allowable Values Allergy/Sensitivity to aspirin Documentation of an aspirin allergy/sensitivity Documentation of Coumadin/warfarin or Pradaxa/dabigatran etexilate prescribed prearrival Coumadin/warfarin or Pradaxa/dabigatran etexilate is prescribed as a pre-arrival home medication Other documented reasons Documentation of reason for not administering aspirin on arrival No documented reason or UTD No documentation of a reason for not administering aspirin on arrival or UTD

74 Notes Reason No Aspirin on Arrival Conflicting information, a positive finding (aspirin allergy) should take precedence over a negative finding (no known allergy) Aspirin allergy or sensitivity documented anytime during the hospital stay counts as an allergy regardless of what type of reaction might be noted Notation of an aspirin allergy prior to arrival counts as a reason for not administering aspirin, abstract yes value 1

75 Reason No Aspirin on Arrival Any physician documentation of a reason for not administering aspirin. (ASA not administered because patient has a gastric ulcer) A documented reason is necessary Aspirin not administered is not sufficient Physician crossing out of an aspirin order counts as an "other reason" for not administering aspirin

76 Notes Reason No Aspirin on Arrival Pre-arrival hold or discontinuation of aspirin or notation such as No aspirin counts as a reason Pre-arrival other reason counts as reason for not administering aspirin (Intolerance to aspirin or Hx GI bleeding with aspirin) In situations where there is documentation that would support more than one of the allowable values, 1-4, select the lowest value. Example: Patient has a documented aspirin allergy and documentation of Coumadin as a pre-arrival medication, abstract value 1

77 OP-5 Median Time to ECG

78 Median Time to ECG Continuous Variable Time (in minutes) from emergency department arrival to ECG (performed in the ED prior to transfer) for AMI or Chest Pain patients (with Probable Cardiac Chest Pain)

79 ECG Date/Time

80 ECG Date/Time In the event the patient had an ECG performed within 60 minutes prior to arrival at the ED, enter the date/time the patient arrived at this ED

81 Outpatient Surgery

82 Surgery - Based Upon Codes Population of the OP-6 and OP-7 Surgical measures use four data elements CPT Code Encounter Date Patients are eligible to be sampled if they have CPT Code for surgery as defined in Table 6.0, and A Patient Age on Encounter Date >= 18 years

83 OP-6 Timing of Antibiotic Prophylaxis

84 Timing of Antibiotic Prophylaxis Numerator Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if initiating vancomycin or fluoroquinolone) Denominator Surgical patients with no evidence of prior infection

85 Exclusions Timing of Antibiotic Prophylaxis Excluded Populations Procedure is canceled prior to incision CPT Code of gastrostomy placement that represents a replacement only Patients enrolled in a Clinical Trial Patients with an Infection Prior to Anesthesia Patients who receive oral or intramuscular antibiotics only

86 Antibiotic

87 Antibiotic Allowable Values Yes - Antibiotic received during this outpatient encounter No - No antibiotics received during this outpatient encounter or UTD

88 Notes Antibiotic Only antibiotics listed in Appendix C, Table 6.0 Appropriate route PO, IV, IM or UTD Only IV ABX scored Must be clear that the dose was administered

89 Antibiotic Antibiotic initiation information should be abstracted from a single source antibiotic name route date & time Do not collect antibiotics documented on the operative report unless the surgeon states that the surgeon actually administered the dose

90 Antibiotic Documentation can be given by one person and be documented as being given by another person if that dose is not documented by the person that actually administered it Authentication on one side/page of a multi-side or multi-page form applies to all pages of the form - The sides/pages of the form must be identifiable as being from the same form

91 Notes for Abstraction Antibiotic Do not abstract antibiotics from sources that do not represent actual administration Do not abstract antibiotics from narrative charting unless there is no other documentation that reflects that the same antibiotic was given during the specified timeframe. Narrative states Ancef 1 gram given IV prior to incision. No other doses of Ancef are documented dose in the narrative should be abstracted using UTD for missing data

92 Antibiotic Urologic and pubovaginal sling procedures only Documentation that oral antibiotic was taken prior to arrival for surgical prophylaxis, enter antibiotic name and route as an antibiotic that was taken during the OP encounter Documentation instructions for oral antibiotics to be taken at home OR documentation of instructions or prescriptions given to the patient in regard to oral antibiotics, assume the antibiotics were taken and collect them as given during the OP encounter If the oral antibiotic is listed on the med reconciliation list or the list of home medications, but there is documentation that the antibiotic is NOT a routine medication, collect this antibiotic as given during the outpatient encounter

93 Antibiotic Route

94 Antibiotic Route Allowable Values PO/NG/PEG tube (Oral) IV (Intravenous) UTD IM (Intramuscular)

95 Antibiotic (cont.) Inclusion Guidelines - all inclusive Intravenous required to score positively IV bolus IV infusion IV I.V. IVPB IV piggyback IV push

96 Antibiotic PO/NG/PEG tube Feeding tube (percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, gastrostomy tube) By mouth Oral Gastric tube G-tube Jejunostomy J-tube Nasogastric tube PO P.O.

97 IM IM I.M. Intramuscular Antibiotic Abstraction

98 Antibiotic Name

99 Antibiotic Name Only use Antibiotic NOS in the following situations For new antibiotics that are not yet listed in Appendix C, OP Table 6.0 Does not score postively When the Antibiotic Name is missing or if there is documentation that a medication was administered and it cannot be determined what the name of the medication is It must be apparent that the medication is an antibiotic

100 Antibiotic Timing

101 Antibiotic Timing Allowable Values Yes - An antibiotic was initiated (started) within 60 minutes (120 minutes for Vancomycin or Quinolones) prior to surgical incision No - An antibiotic was not initiated (started) within 60 minutes (120 minutes for Vancomycin or Quinolones) prior to surgical incision or UTD

102 Notes Antibiotic Timing Applies to the antibiotics administered via the intravenous route only. Do NOT consider antibiotics that are given orally for this data element Antibiotic initiation information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic

103 Notes Antibiotic Timing If the route for the antibiotic(s) given within the 60 minutes (120 minutes for vancomycin and quinolones) prior to incision is unable to be determined, abstract No If more than one procedure from OP Table 6.0 was performed during the same surgical episode, the incision time will be the incision that occurs first If no incision time is documented, use the priority list of synonyms

104 Priority Antibiotic Timing Undocumented incision time follow the priority order list of synonyms. If multiple times use earliest time among the highest priority of synonyms First priority: Incision Time Second priority: Surgery start/begin time or operation start time or Procedure start time or Start of surgery or Case start time Third priority: Anesthesia begin time or Anesthesia start time or Operating room start time

105 Antibiotic Timing Two procedures performed during the same surgical episode and procedure not on Table 6.0, the incision time OR surgery start time of the first procedure should be used to determine Antibiotic Timing if IV antibiotics were given prior to the first procedure. If antibiotics were not given for the first procedure, use the incision time or other priority terms for the procedure on Table 6.0 Some procedures that are done during same surgical episode should not be considered procedures that involve an incision - An example would be central line placement or electrophysiology study performed before a procedure on Table 6.0

106 Lap to Open - Antibiotic Timing Laparoscopy to Open If the procedure starts as a laparoscopic procedure and it is converted to an open procedure, the incision time will be the incision that is documented for the open procedure.

107 Case Canceled

108 Case Canceled Abract yes to case canceled Case canceled before an incision was made Documentation canceled without documentation of puncture or incision Case canceled prior to anesthesia start or procedure start and no incision made Abstract no to case canceled Unable to determine whether the case was canceled prior to incision, abstract No

109 Infection Prior to Anesthesia

110 Infection Prior to Anesthesia Allowable Values Yes Physician documentation that the patient had an infection during this outpatient encounter prior to surgery No - No physician documentation that the patient had an infection during this outpatient encounter prior to surgery, or UTD

111 Infection Prior to Anesthesia Abstract Yes Preoperative documentation of an infection or possible or suspected infection Physician documentation of preoperative infection must be in place prior to surgery Do not accept documentation of infection documented after incision time Abstract No Symptoms (fever, elevated white blood cells, etc.) should not be considered an infection

112 Inclusions Infection Prior to Anesthesia Abscess Acute abdomen Aspiration pneumonia Bloodstream infection Bone infection Cellulitis Crohn s disease Endometritis Fecal Contamination Free air in abdomen Gangrene H. pylori Necrosis Necrotic/ischemic/infarcted bowel Osteomyelitis Other documented infection Penetrating abdominal trauma Perforation of bowel Pneumonia or other lung infection Purulence/Pus Sepsis Surgical site or wound infection Ulcerative colitis Urinary tract infection (UTI)

113 Exclusions Infection Prior to Anesthesia Avascular necrosis Bacteria in urine/bacteruria carditis (such as pericarditis) without mention of an infection Colonization or positive screens for MRSA, VRE, or for other bacteria Fungal infections History of infection, recent infection or recurrent infection not documented as a current or active infection Viral infections

114 Replacement

115 Replacement Allowable Values Yes - The procedure performed was a replacement of a previously placed gastrostomy tube No - The procedure performed was not a replacement of a previously placed gastrostomy tube or UTD

116 Notes Replacement Yes replace PEG tube replacement Documentation case is to REPLACE a PEG tube that has been placed previously No to PEG tube If this procedure is NOT to replace a gastrostomy tube

117 OP-7 Prophylactic Antibiotic Selection for Surgical Patients

118 Prophylactic Antibiotic Selection for Surgical Patients Numerator Surgical patients who received prophylactic antibiotics recommended for their specific operation Denominator Surgical patients with no evidence of prior infection

119 Exclusions Prophylactic Antibiotic for Surgical Patients Excluded Populations CPT Code of gastrostomy placement that represents a Replacement only Patients enrolled in a Clinical Trial Patients with an Infection Prior to Anesthesia Do not receive any antibiotics during the encounter

120 Antibiotic Allergy

121 Antibiotic Allergy Allowable Values Yes - Documentation that the patient has an antibiotic allergy to beta-lactam, penicillin, or cephalosporins (either history or current finding) No - No documentation that the patient had an allergy to beta-lactam, penicillin, or cephalosporins or UTD

122 Notes Antibiotic Allergy Abstract as Yes If the patient was noted to be allergic to cillins, penicillin, or all cillins If one source in the record documents Allergies: penicillin and another source in the record documents penicillin causes upset stomach If a physician documents a specific reason not to give penicillin, beta-lactams, or cephalosporins

123 AXB Allergy Adverse drug event Adverse effect Adverse reaction Anaphylaxis Anaphylactic reaction Hives Rash Antibiotic Allergy

124 Vancomycin

125 Vancomycin Allowable Values: Select all that apply Beta-lactam (penicillin or cephalosporin) allergy Physician or pharmacist documentation of MRSA colonization or infection Documentation of patient being high-risk due to acute inpatient hospitalization within the last year Documentation of patient being high-risk due to nursing home or extended care facility setting within the last year, prior to admission Physician or pharmacist documentation of increased MRSA rate, either facility-wide or operation-specific Physician or pharmacist documentation of chronic wound care or dialysis Other physician or pharmacist documented reason No documented reason/unable to Determine

126 Vancomycin (continued) Documentation must be present preoperative In order to select allowable value 1 for Documentation of beta-lactam (penicillin or cephalosporin) allergy, the answer to the data element Antibiotic Allergy must be Yes

127 Hospitalization Guidelines Hospitalization Acute inpatient Federal or VA facility Hospice - Acute facility Inpatient drug rehabilitation Inpatient rehabilitation unit or facility Long-term care hospital

128 Nursing Home Vancomycin Inclusion - Nursing Home or Extended Care Facility Hospice Skilled/Respite Intermediate care facility (ICF) Respite care Skilled nursing facility (SNF) or SNF rehabilitation unit Sub-acute care Swing bed/unit Transitional care unit (TCU)

129 Vancomycin Exclusion Hospital or Extended Care Exclusion Guidelines Assisted Living Board and Care Group home/personal care homes Hospice at home Psychiatric unit or facility Residential care Residential or outpatient chemical dependency treatment

130 Questions Discussion