Natinal Hspital Inpatient Quality Reprting Measures Specificatins Manual Release Ntes Fr Manual Versin: 5.3 Cmpleted: June 15, 2017 Guidelines fr Using Release Ntes The Release Ntes prvides mdificatins t the Specificatins Manual fr Natinal Hspital Inpatient Quality Measures, Versin 5.3. 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 01/01/2018, 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.
Table f Cntents Release Ntes Versin 5.3 Nte: click n any sectin title in the Release Ntes t return t Table f Cntents page. Table f Cntents... 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... 2 Alphabetical Data Dictinary... 3 SECTION 2 Measurement Infrmatin... 65 Subsectin 2.1 Severe Sepsis and Septic Shck (SEP)... 65 Subsectin 2.2 Venus Thrmbemblism (VTE)... 67 Subsectin 2.4 Glbal Initial Patient Ppulatin (ED, IMM, TOB, SUB) (n updates)... 67 Subsectin 2.5 Emergency Department (ED)... 68 Subsectin 2.6 - Preventin... 68 2.6.1 - Immunizatin (IMM)... 68 2.6.2 - Substance Use (SUB)... 68 2.6.3 - Tbacc Treatment (TOB)... 69 SECTION 3 Missing and Invalid Data (n updates)... 75 SECTION 4 Ppulatin and Sampling Specificatins (n updates)... 75 SECTION 9 Data Transmissin... 75 Transmissin Overview... 75 Transmissin Alphabetical Data Dictinary (n updates)... 76 Hspital Clinical Data XML File Layut... 76 Hspital Initial Patient Ppulatin Data XML File Layut (n updates)... 85 SECTION 10 CMS Outcme/Structural Measures... 85 Subsectin 10.1 CMS Outcme Measures (n updates)... 85 Subsectin 10.2 Structural Measures (n updates)... 85 APPENDICES... 86 Appendix A ICD-10 Cde Tables (Wrd and Excel n updates)... 86 Appendix C Medicatin Tables (Wrd and Excel)... 86 Appendix D Glssary f Terms (n updates)... 86 Appendix E Overview f Measure Infrmatin Frm and Flwchart Frmats (n updates)... 86 Appendix F Measure Name Crsswalk (n updates)... 86 Appendix G Resurces (n updates)... 86 Appendix H Miscellaneus Tables (n updates)... 86 Appendix P Preview Sectin (n updates)... 86 Page 1
The cntent belw is rganized t fllw the Table f Cntents in the specificatins manual. Table f Cntents Sectin 2.6.2 - Substance Use (SUB) Ratinale: Effective January 1, 2018, the SUB-4 measure is being retired and will nt be available fr selectin in meeting Jint Cmmissin ORYX Perfrmance Measure Reprting Requirements. Remve under Measure Infrmatin Frm (MIF) and Flwchart (Algrithm): SUB-4 Sectin 2.6.3 Tbacc Treatment (TOB) Ratinale: Effective January 1, 2018, the TOB-4 measure is being retired and will nt be available fr selectin in meeting Jint Cmmissin ORYX Perfrmance Measure Reprting Requirements. Remve under Measure Infrmatin Frm (MIF) and Flwchart (Algrithm): TOB-4 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 Intrductin Ratinale: The data element Patient HIC# is being deleted as it is nt used by CMS in the abstractin prcess and may cntain the patients Scial Security Number. Remve frm data element list: Patient HIC# Page 2
Alphabetical Data Dictinary Index and Data Elements Ratinale: Effective January 1, 2018, the SUB-4 and TOB-4 measures are being retired and will nt be available fr selectin in meeting Jint Cmmissin ORYX Perfrmance Measure Reprting Requirements. Remve rws in index and data elements in their entirety: Alchl r Drug Use Status Pst Discharge Cunseling Alchl r Drug Use Status Pst Discharge - Medicatin Alchl Use Status Pst Discharge Quit Status Drug Use Status Pst Discharge Quit Status Fllw-up Cntact Fllw-up Cntact Date Tbacc Use Status Pst Discharge - Cunseling Tbacc Use Status Pst Discharge - Medicatin Tbacc Use Status Pst Discharge Quit Status Administrative Cntraindicatin t Care, Septic Shck Ratinale: The and Inclusin Guidelines fr Abstractin are being updated t prvide additinal guidance t the abstractr. Only acceptable surces are physician/apn/pa r nursing dcumentatin. Dcumentatin indicating patient r authrized patient advcate has refused bld draws, IV r IO fluid administratin, r vaspressr administratin prir t r within 6 hurs fllwing presentatin f septic shck can be used t select Value 1. Dcumentatin f refusal f care that wuld result in bld draws, IV r IO fluids r vaspressrs nt being administered is acceptable. If intrasseus access r placement f a central line is refused, cnsider this refusal f vaspressrs. Fr refusal f bld draws: 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). Fr refusal f IV r IO fluids: Dcumented refusal f fluids r IV r IO fluids is acceptable. Fr refusal f vaspressr: Dcumented refusal f medicatins r vaspressrs is acceptable. Page 3
Inclusin Guidelines fr Abstractin: Declined Refused Requests nt t be given Administrative Cntraindicatin t Care, Severe Sepsis Ratinale: The and Inclusin Guidelines fr Abstractin are being updated t prvide additinal guidance t the abstractr. Only acceptable surces are physician/apn/pa r nursing dcumentatin. Dcumentatin indicating patient r authrized patient advcate has refused bld draw, IV r IO fluid administratin, r IV r IO antibitic administratin prir t r within 6 hurs fllwing presentatin f severe sepsis can be used t select Value 1. Dcumentatin f refusal f care that wuld result in bld draws, IV r IO fluids r IV r IO antibitics nt being administered is acceptable. Fr refusal f bld draws: 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). Fr refusal f IV r IO fluids: Dcumented refusal f fluids r IV r IO fluids is acceptable. Fr refusal f IV r IO antibitic administratin: Dcumented refusal f medicatins is acceptable. Dcumented refusal f antibitics r IV r IO antibitics is acceptable. Inclusin Guidelines fr Abstractin Declined Refused Requests nt t be given Alchl Use Status Ratinale: The data element is being updated t prvide clarificatin f the screening time frame, cnversin infrmatin n the bld alchl level, and guidance n screening f the intubated patient. Definitin Change first sentence t: Page 4
Dcumentatin f the adult patient s alchl use status using a validated screening questinnaire fr unhealthy alchl use within the first day f admissin (by end f Day 1). Allwable Values Change frm: 1 The patient is screened with a validated tl within the first day f admissin and the scre n the alchl screen indicates n r lw risk f alchl related prblems. 2 The patient was screened with a validated tl within the first day f admissin and the scre n the alchl screen indicates unhealthy alchl use (mderate r high risk) benefiting frm brief interventin. 3 The patient was screened with a nn-validated tl within the first day f admissin and the scre n the alchl screen indicates n r lw risk f alchl related prblems. 4 The patient was screened with a nn-validated tl within the first day f admissin and the scre n the alchl screen indicates unhealthy alchl use (mderate r high risk) benefiting frm brief interventin. 5 The patient refused the screen fr alchl use within the first day f admissin. 6 The patient was nt screened fr alchl use during the first day f admissin r unable t determine frm medical recrd dcumentatin. 7 The patient was nt screened fr alchl use during the first day f admissin because f cgnitive impairment. T: 1 The patient is screened with a validated tl within the first day f admissin (by end f Day 1) and the scre n the alchl screen indicates n r lw risk f alchl related prblems. 2 The patient was screened with a validated tl within the first day f admissin (by end f Day 1) and the scre n the alchl screen indicates unhealthy alchl use (mderate r high risk) benefiting frm brief interventin. 3 The patient was screened with a nn-validated tl within the first day f admissin (by end f Day 1) and the scre n the alchl screen indicates n r lw risk f alchl related prblems. 4 The patient was screened with a nn-validated tl within the first day f admissin (by end f Day 1) and the scre n the alchl screen indicates unhealthy alchl use (mderate r high risk) benefiting frm brief interventin. 5 The patient refused the screen fr alchl use within the first day f admissin (by end f Day 1). 6 The patient was nt screened fr alchl use within the first day f admissin (by end f Day 1) r unable t determine frm medical recrd dcumentatin. 7 The patient was nt screened fr alchl use within the first day f admissin (by end f Day 1) because f cgnitive impairment. 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 Page 5
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. 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 with dcumented symptms, e.g., hallucinating, nncmmunicative, catatnic, etc., which prevented them frm answering questins reliably, they wuld 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 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. Page 6
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. 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 cunseled due t cgnitive impairment. 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 Dementia Cnfused Memry lss Mentally retarded Obtunded Psychtic/psychsis Bedside Cardivascular Ultrasund Date Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin On what date was a bedside cardivascular ultrasund perfrmed? Bedside Cardivascular Ultrasund Date Ratinale: The are being updated t include additinal guidance t the abstractr. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Add new secnd bullet pint: If there are multiple bedside cardivascular ultrasunds perfrmed, abstract the date and time f the latest measurement dcumented within the allwable time windw. Page 7
Remve last bullet pint: If multiple bedside cardivascular ultrasunds were dne in the time windw beginning at the crystallid fluid administratin date and time and ending six hurs after the presentatin f septic shck date and time, abstract the date f the prcedure that was dne latest within the time windw. Bedside Cardivascular Ultrasund Perfrmed Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin Was a bedside cardivascular ultrasund perfrmed? Bedside Cardivascular Ultrasund Perfrmed Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are n assessments perfrmed. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Remve fifth bullet pint: If multiple bedside cardivascular ultrasunds were dne in the time windw beginning at the crystallid fluid administratin date and time and ending six hurs after the presentatin f septic shck date and time, abstract the date f the prcedure that was dne latest within the time windw. Change last bullet pint t: If n bedside cardivascular ultrasunds were dcumented r dcumentatin reflects the assessment was nt perfrmed in the allwable time windw, chse Value 2. Bedside Cardivascular Ultrasund Time Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin At what time was a bedside cardivascular ultrasund perfrmed? Page 8
Bedside Cardivascular Ultrasund Time Ratinale: The are being updated t include additinal guidance t the abstractr. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Add new secnd bullet pint: If there are multiple bedside cardivascular ultrasunds perfrmed, abstract the time f the latest measurement dcumented within the allwable time windw. Remve last bullet pint: If multiple bedside cardivascular ultrasunds were dne in the time windw beginning at the crystallid fluid administratin date and time and ending six hurs after the presentatin f septic shck date and time, abstract the time f the prcedure that was dne latest within the time windw. Bld Culture Cllectin Acceptable Delay Ratinale: The are being updated t prvide additinal guidance t the abstractr. Change first bullet pint t: Only the fllwing situatins demnstrate an acceptable delay, resulting in the bld culture being drawn after the Brad Spectrum r Other Antibitic Administratin Date and Time. If there is an acceptable delay, chse Value 1. Change first sub-bullet pint, under first bullet pint t: Surgical patients wh receive a pre-p r pst-p prphylactic antibitic and within 24 hurs f that antibitic dse develp severe sepsis and then have a bld culture drawn. Remve frm the secnd and third sub-bullet pints: IV Change furth sub-bullet pint t: A physician/apn/pa dcumented reasn fr the delay, such as waiting t start the antibitic r t draw the bld culture culd cause a delay which wuld be detrimental t the patient. Add new fifth sub-bullet pint, under first bullet pint: Obstetric patients given prphylactic antibitics fr ruptured membranes, grup B strep, r prir t a caesarean sectin. Page 9
Remve the secnd bullet pint: If there is dcumentatin supprting an acceptable delay in the cllectin f a bld culture, chse Value 1. Brief Interventin Ratinale: An update is being made t the Suggested Data Surces t prvide clarificatin fr abstractin. Suggested Data Surces Remve first bullet pint: Cding dcuments Brad Spectrum r Other Antibitic Administratin Ratinale: The Definitin, Suggested Data Cllectin Questin, and Allwable Values were updated t remve intravenus rute. Definitin, Suggested Data Cllectin Questin, Allwable Values Remve: Intravenusly Allwable Values Change frm: 1 (Yes) A brad spectrum r ther antibitic was administered intravenusly in the time windw 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis. 2 (N) N antibitic was administered intravenusly in the time windw 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis, r unable t determine. T: 1 (Yes) A brad spectrum r ther antibitic was administered in the time windw 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis. 2 (N) N antibitic was administered in the time windw 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis, r unable t determine. Brad Spectrum r Other Antibitic Administratin Ratinale: The are being updated t prvide additinal guidance t the abstractr. Change first bullet pint t: Only IV antibitic administered in the 24 hurs prir t r 3 hurs after severe sepsis presentatin is acceptable. EXCEPTION: If there is dcumentatin indicating IV access culd nt be established, antibitics administered via intramuscular (IM) r intrasseus (IO) started in the Page 10
24 hurs prir t r 3 hurs after the severe sepsis presentatin is acceptable t select Value 1. Change secnd, third, furth, and fifth bullet pints t: If the patient started n an antibitic within the 24 hurs preceding r 3 hurs fllwing the Severe Sepsis Presentatin Date and Time, chse Value 1. If n antibitic was started within the 24 hurs preceding r 3 hurs fllwing the Severe Sepsis Presentatin Date and Time, chse Value 2. Antibitic administratin infrmatin shuld nly be abstracted frm dcumentatin that demnstrates actual administratin f the antibitic (i.e., antibitic name, rute, date and time). A physician/apn/pa rder fr antibitics is nt sufficient unless the antibitic rdered was marked as started with date/time nted. Change seventh and eighth bullet pints t: D nt crss reference between different surces t infer that an antibitic was started if it was dcumented nly with name/date/time given but n rute indicated. The rute n the MAR fr an antibitic cannt be used as the rute fr a dse f that same antibitic n anther frm. The methd f designatin f administratin n hand-written r pre-printed frms such as MARs r emars, with pre-printed scheduled times fr administratin, must be clearly designated as started. The methds may vary. Whatever methd is used, it must be clear that the dse was administered. Add new twelfth bullet pint: If the antibitic name, rute, date r time is missing, disregard that dse. Change last bullet pint t: Pre-hspital recrds (e.g., ambulance recrds, nursing hme recrds) that are cnsidered part f the medical recrd shuld be used fr abstracting antibitics. Brad Spectrum r Other Antibitic Administratin Brad Spectrum r Other Antibitic Administratin Date Brad Spectrum r Other Antibitic Administratin Selectin Brad Spectrum r Other Antibitic Administratin Time Ratinale: The Inclusin Guidelines fr Abstractin are being updated t include additinal rutes that are acceptable. Inclusin Guidelines fr Abstractin Add new bullet pints: Intramuscular r IM Intrasseus r IO Page 11
Brad Spectrum r Other Antibitic Administratin Date Ratinale: The are being updated t include additinal guidance t the abstractr. Only IV antibitic administered in the 24 hurs prir t r 3 hurs after severe sepsis presentatin is acceptable. EXCEPTION: If there is dcumentatin indicating IV access culd nt be established, antibitics administered via intramuscular (IM) r intrasseus (IO) started in the 24 hurs prir t r 3 hurs after the severe sepsis presentatin is acceptable. If ne r mre antibitic was started within the 24 hurs prir t presentatin f severe sepsis, and nne f thse same antibitics were started mre than 24 hurs prir t presentatin, abstract the earliest dse started in the 24 hurs prir t presentatin f severe sepsis. If ne r mre antibitics were administered within 24 hurs prir t severe sepsis presentatin, abstract the earliest date and time that antibitic was started. This may be the same date as the date f presentatin r may be a date any time befre presentatin. D nt review fr antibitic dses started mre than 72 hurs prir t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs.) 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract A A A First dse f A B C C Antibitic B G A A A First dse f A B B B First dse f B C D C C First dse f C If ne r mre antibitic was started within the 3 hurs after presentatin f severe sepsis, and the patient did nt receive an antibitic in the 24 hurs befre severe sepsis presentatin, abstract the dse started clsest t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs. frm presentatin) 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract E L Antibitic L K K A Dse f K in 3 hr. perid If antibitics were administered bth 24 hurs prir t and within 3 hurs after the time f presentatin f severe sepsis, abstract the earliest date and time that an antibitic in the 24 hurs prir was started. This may be the same date as the date f presentatin Page 12
r may be a date any time befre presentatin. D nt review fr antibitic dses started mre than 72 hurs prir t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs. frm presentatin) E 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract D D D First dse f D F Antibitic E E E E L First dse f E M A B A M First dse f A M A B M A M First dse f M Stp abstracting 3 hurs after the presentatin f severe sepsis. If n antibitic was started in the 24 hurs befre r 3 hurs after severe sepsis presentatin, enter UTD. D nt crss reference between different surces t infer that an antibitic was started if it was dcumented nly with name/date/time given but n rute indicated. The rute n the MAR fr an antibitic cannt be used as the rute fr a dse f the same antibitic n anther frm. If the antibitic name, rute, date r time is missing, disregard that dse. Antibitic administratin infrmatin shuld nly be abstracted frm dcumentatin that demnstrates actual administratin f the specific antibitic within the time windw f 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis. Examples: A physician rder fr IV antibitics is nt sufficient unless the antibitic rdered was marked as started with date/time nted. D nt cllect antibitics dcumented n an perative reprt unless the surgen states that the surgen actually administered the dse. Specific dcumentatin by ne persn that anther persn administered the antibitic is acceptable fr determining the date and time f administratin. Example: OR nurse, S. Smith RN, dcuments, Cefazlin 1 gm IV given n 1/7/20xx at 0500 per J De RN. This dse can be abstracted as given if nt dcumented by the persn that gave the dse. The methd f designatin f administratin n hand-written r pre-printed frms such as MARs r emars, with pre-printed scheduled times fr administratin, must be clearly designated as started. The methds may vary. Whatever methd is used, it must be clear that the dse was administered. D nt abstract test dses f antibitics. D nt abstract antibitics frm surces that d nt represent actual administratin. Page 13
Examples that d nt represent actual administratin: Pre-Op Checklist states: X IV Started at 1730 X Prep Antibitic Given at 1800 X Lab n Chart Operative reprt states: IV antibitics were given prir t prcedure D nt abstract antibitics frm narrative charting unless there is n ther dcumentatin that reflects that the same antibitic was started during the specified timeframe. Example: Narrative states: Ancef 1 gram given IV prir t incisin. N ther dses f Ancef are dcumented. The dse in the narrative shuld be abstracted using UTD fr missing data (n date and time). Pre-hspital recrds (e.g., ambulance recrds, nursing hme recrds) that are cnsidered part f the medical recrd shuld be used fr abstracting antibitics. Brad Spectrum r Other Antibitic Administratin Date Brad Spectrum r Other Antibitic Administratin Time Ratinale: The Definitin, Suggested Data Cllectin Questin, and Allwable Values are being updated t remve intravenus rute. Definitin, Suggested Data Cllectin Questin Change: administered intravenusly if given T: started Brad Spectrum r Other Antibitic Administratin Time Ratinale: The are being updated t include additinal guidance t the abstractr. Only IV antibitic administered in the 24 hurs prir t r 3 hurs after severe sepsis presentatin is acceptable. EXCEPTION: If there is dcumentatin indicating IV access culd nt be established, antibitics administered via intramuscular (IM) r intrasseus (IO) started in the 24 hurs prir t r 3 hurs after the severe sepsis presentatin is acceptable. If ne r mre antibitic was started within the 24 hurs prir t presentatin f severe sepsis, and nne f thse same antibitics were started mre than 24 hurs prir t presentatin, abstract the earliest dse started in the 24 hurs prir t presentatin f severe sepsis. Page 14
If ne r mre antibitics were administered within 24 hurs prir t severe sepsis presentatin, abstract the earliest date and time that antibitic was started. This may be the same time as the time f presentatin r may be a time befre presentatin. D nt review fr antibitic dses started mre than 72 hurs prir t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs.) 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract A A A First dse f A B C C Antibitic B G A A A First dse f A B B B First dse f B C D C C First dse f C If ne r mre antibitic was started within the 3 hurs after the presentatin f severe sepsis, and the patient did nt receive an antibitic in the 24 hurs befre severe sepsis presentatin, abstract the dse started clsest t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs. frm presentatin) 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract E L Antibitic L K K A Dse f K in 3 hr. perid If antibitics were administered bth 24 hurs prir t and within 3 hurs after the time f presentatin f severe sepsis, abstract the earliest date and time that an antibitic in the 24 hurs prir was started. This may be the same time as the time f presentatin r may be a time befre presentatin. D nt review fr antibitic dses started mre than 72 hurs prir t severe sepsis presentatin. Examples: Mre than 24 hurs Befre Presentatin (Max. lkback 72 hrs. frm presentatin) 24 hurs Befre Presentatin Severe Sepsis 3 Hurs After Presentatin Antibitic Dse t Abstract D D D First dse f D E F Antibitic E E E E L First dse f E M A B A M First dse f A M A B M A M First dse f M Page 15
Stp abstracting 3 hurs after the presentatin f severe sepsis. If n antibitic was started in the 24 hurs befre r 3 hurs after the severe sepsis presentatin, enter UTD. D nt crss reference between different surces t infer that an antibitic was started if it was dcumented nly with name/date/time given but n rute indicated. The rute n the MAR fr an antibitic cannt be used as the rute fr a dse f the same antibitic n anther frm. If the antibitic name, rute, date r time is missing, disregard that dse. Antibitic administratin infrmatin shuld nly be abstracted frm dcumentatin that demnstrates actual administratin f the specific antibitic within the time windw f 24 hurs prir t r 3 hurs fllwing the presentatin f severe sepsis. Examples: A physician rder fr IV antibitics is nt sufficient unless the antibitic rdered was marked as given with date/time nted. D nt cllect antibitics dcumented n an perative reprt unless the surgen states that the surgen actually administered the dse. Specific dcumentatin by ne persn that anther persn administered the antibitic is acceptable fr determining the date and time f administratin. Example: OR nurse, S. Smith RN, dcuments, Cefazlin 1 gm IV given n 1/7/20xx at 0500 per J De RN. This dse can be abstracted as given if nt dcumented by the persn that gave the dse. The methd f designatin f administratin n hand-written r pre-printed frms such as MARs r emars, with pre-printed scheduled times fr administratin, must be clearly designated as started. The methds may vary. Whatever methd is used, it must be clear that the dse was administered. D nt abstract test dses f antibitics. D nt abstract antibitics frm surces that d nt represent actual administratin. Examples that d nt represent actual administratin: Pre-Op Checklist states: X IV Started at 1730 X Prep Antibitic Given at 1800 X Lab n Chart Operative reprt states: IV antibitics were given prir t prcedure D nt abstract antibitics frm narrative charting unless there is n ther dcumentatin that reflects that the same antibitic was started during the specified timeframe. Example: Narrative states: Ancef 1 gram given IV prir t incisin. N ther dses f Ancef are dcumented. The dse in the narrative shuld be abstracted using UTD fr missing data (n date and time). Pre-hspital recrds (e.g., ambulance recrds, nursing hme recrds) that are cnsidered part f the medical recrd shuld be used fr abstracting antibitics. Page 16
Brad Spectrum r Other Antibitic Administratin Selectin Ratinale: The Definitin, Suggested Data Cllectin Questin, and Allwable Values are being updated t remve intravenus rute. Definitin, Suggested Data Cllectin Questin Remve: Intravenus (IV) Allwable Values Change frm: 1 (Yes) The IV antibitic that was given within 3 hurs fllwing the presentatin f severe sepsis is cnsistent with antibitic selectin guidelines. 2 (N) The IV antibitic that was given within 3 hurs fllwing the presentatin f severe sepsis is nt cnsistent with antibitic selectin guidelines. T: 1 (Yes) The antibitic that was given within 3 hurs fllwing the presentatin f severe sepsis is cnsistent with antibitic selectin guidelines. 2 (N) The antibitic that was given within 3 hurs fllwing the presentatin f severe sepsis is nt cnsistent with antibitic selectin guidelines. Brad Spectrum r Other Antibitic Administratin Selectin Ratinale: The are being updated t include additinal guidance t the abstractr. Only IV antibitic administered 3 hurs after severe sepsis presentatin is acceptable. EXCEPTION: If there is dcumentatin indicating IV access culd nt be established, antibitics administered via intramuscular (IM) r intrasseus (IO) started 3 hurs after the severe sepsis presentatin is acceptable t select value 1. Antibitic administratin infrmatin shuld nly be abstracted frm dcumentatin that demnstrates actual administratin f the antibitic within the 3 hurs fllwing Severe Sepsis Presentatin Date and Time. 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 Page 17
sepsis presentatin and if s, chse Value 1. If bth drugs were nt started within 3 hurs, chse Value 2. Cmbinatin Antibitic Therapy Table Clumn A Aminglycsides OR Aztrenam OR Ciprflxacin Clumn B + Cephalsprins (1st and 2nd Generatin) OR Clindamycin IV OR Daptmycin OR Glycpeptides OR Linezlid OR Macrlides OR Penicillins If an antibitic frm Table 5.0 r an apprpriate cmbinatin f antibitics frm Table 5.1 is nt started r given within the 3 hurs fllwing presentatin f severe sepsis, but there is a lab reprt r physician/apn/pa dcumentatin indicating the causative rganism and susceptibility is knwn (see exceptin fr C. difficile) and an antibitic identified as apprpriate t treat the causative rganism is given within 3 hurs fllwing presentatin f severe sepsis, chse Value "1." Cultures are nt limited t bld cultures If a causative rganism with a susceptible antibitic are used, the causative rganism must be identified frm cultures cllected in the perid 24 hurs prir t the antibitic being started, r within 3 hurs fllwing severe sepsis presentatin. Cultures r dcumentatin referring t cultures btained utside f this time perid shuld nt be used. Exceptin fr C. difficile: If the causative rganism is identified as C. difficile, susceptibility testing is nt required, and if the patient is receiving ral vancmycin with r withut ral r IV metrnidazle (Flagyl), chse Value 1. Cultures are nt limited t bld cultures C-diff must be identified frm cultures cllected in the perid 24 hurs prir t the antibitic being started, r within 3 hurs fllwing severe sepsis presentatin. Cultures r dcumentatin referring t cultures btained utside f this time perid shuld nt be used. Capillary Refill Examinatin Date Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin On what date was a capillary refill examinatin dcumented by a physician/apn/pa? Capillary Refill Examinatin Date Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Page 18
Change first bullet pint t: Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Change third bullet pint t: If there are multiple capillary refill examinatins perfrmed, abstract the date f the latest measurement dcumented within the allwable time windw. Capillary Refill Examinatin Perfrmed Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin Was a capillary refill examinatin dcumented by a physician/apn/pa? Capillary Refill Examinatin Perfrmed Ratinale: The were updated t prvide guidance n the timeframe and hw t determine if the assessment was perfrmed. Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Capillary refill examinatin can be dcumented by any ne f the fllwing 3 ways: Physician/APN/PA dcumentatin f an inclusin term. Example: Physician/APN/PA dcumentatin f capillary refill less than 3 secnds wuld be sufficient. Physician/APN/PA dcumentatin that a capillary refill exam was reviewed, perfrmed, r attested t reviewing r perfrming. Example: Physician/APN/PA dcuments nurses capillary refill exam reviewed wuld be sufficient. Physician/APN/PA dcumentatin f perfrming r attesting t perfrming a physical exam, perfusin (re-perfusin) assessment, r sepsis (severe sepsis r septic shck) fcused exam. Example: Physician/APN/PA dcuments sepsis exam dne. A title r heading f a frm, sectin, r assessment shuld nt be used. Page 19
Example: In the H&P there is a heading called physical exam. If there are n capillary refill examinatins dcumented r dcumentatin reflects the assessment was nt perfrmed in the allwable time windw, chse Value 2. If the capillary refill examinatin is in a physician/apn/pa nte withut a specific time, use the time the nte was started r pened. Capillary Refill Examinatin Time Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin At what time was a capillary refill examinatin dcumented by a physician/apn/pa? Capillary Refill Examinatin Time Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Change first bullet pint t: Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Change third bullet pint t: If there are multiple capillary refill examinatins perfrmed, abstract the time f the latest measurement dcumented within the allwable time windw. Cardipulmnary Evaluatin Date Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin On what date was a cardipulmnary evaluatin dcumented by a physician/apn/pa? Cardipulmnary Evaluatin Date Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Page 20
Change first bullet pint t: Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Change third bullet pint t: If there are multiple cardipulmnary evaluatins perfrmed, abstract the date f the latest measurement dcumented within the allwable time windw. Cardipulmnary Evaluatin Perfrmed Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin Was a cardipulmnary evaluatin dcumented by a physician/apn/pa? Cardipulmnary Evaluatin Perfrmed Ratinale: The were updated t prvide guidance n the timeframe and hw t determine if the assessment was perfrmed. Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Cardipulmnary evaluatin can be dcumented by any ne f the fllwing 3 ways: Physician/APN/PA dcumentatin must reference the heart, lungs and the findings. Example: Physician/APN/PA dcuments Lungs clear, heart within nrmal limits. Physician/APN/PA dcumentatin that a cardipulmnary evaluatin was reviewed, perfrmed, r attested t reviewing r perfrming. Referencing the heart, lungs and the findings are nt required. Example: Physician/APN/PA dcuments Reviewed and agree with the nurse s cardipulmnary assessment. Physician/APN/PA dcumentatin f perfrming r attesting t perfrming a physical exam, perfusin (re-perfusin) assessment, r sepsis (severe sepsis r septic shck) fcused exam. Example: Physician/APN/PA dcuments sepsis exam dne. Page 21
A title r heading f a frm, sectin, r assessment shuld nt be used. Example: In the H&P there is a heading called physical exam. If there are n cardipulmnary evaluatins dcumented r dcumentatin reflects the assessment was nt in the allwable time windw, chse Value 2. If cardipulmnary evaluatin is in a physician/apn/pa nte withut a specific time, use the time the nte was started r pened. Cardipulmnary Evaluatin Time Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin At what time was a cardipulmnary evaluatin dcumented by a physician/apn/pa? Cardipulmnary Evaluatin Time Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Change first bullet pint t: Physician/APN/PA dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Change third bullet pint t: If there are multiple cardipulmnary evaluatins perfrmed, abstract the time f the latest measurement dcumented within the allwable time windw. Central Venus Oxygen Measurement Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin Was a central venus xygen measurement btained? Central Venus Oxygen Measurement Ratinale: The were updated t prvide guidance n the timeframe and hw t abstract if an assessment was nt perfrmed. Page 22
Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Remve secnd bullet pint: If there are multiple central venus xygen measurements dcumented in the time windw beginning at the crystallid fluid administratin date and time and ending six hurs after the presentatin f septic shck date and time, abstract the date and time f the measurement that was dcumented latest within the time windw. Change last bullet pint t: If there are n central venus xygen measurements dcumented r dcumentatin reflects the assessment was nt perfrmed in the allwable time windw, chse Value 2. Central Venus Oxygen Measurement Date Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin What was the date n which the central venus xygen measurement was btained? Central Venus Oxygen Measurement Date Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Add new secnd bullet pint: If there are multiple central venus xygen measurements perfrmed, abstract the date f the latest measurement dcumented within the allwable time windw. Central Venus Oxygen Measurement Time Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Page 23
Suggested Data Cllectin Questin What was the time at which a central venus xygen measurement was btained? Central Venus Oxygen Measurement Time Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Add new secnd bullet pint: If there are multiple central venus xygen measurements perfrmed, abstract the time f the latest measurement dcumented within the allwable time windw. Central Venus Pressure Measurement Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin Was a central venus pressure measurement btained? Central Venus Pressure Measurement Ratinale: The were updated t prvide guidance n the timeframe and hw t abstract if an assessment was nt perfrmed. Change first bullet pint t: Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. Remve secnd bullet pint: If there are multiple central venus pressure measurements dcumented in the time windw beginning at the crystallid fluid administratin date and time and ending six hurs after the presentatin f septic shck date and time, abstract the date and time f the measurement that was dcumented latest within the time windw. Page 24
Change last bullet pint t: If there are n central venus pressure measurements dcumented r dcumentatin reflects the assessment was nt perfrmed in the allwable time windw, chse Value 2. Central Venus Pressure Measurement Date Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin What was the date n which a central venus pressure measurement was btained? Central Venus Pressure Measurement Date Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. If there are multiple central venus pressure measurements perfrmed, abstract the date f the latest measurement dcumented within the allwable time windw. Central Venus Pressure measurement may be expressed as CVP, central venus pressure, r RAP, right atrial pressure. Central Venus Pressure Measurement Time Ratinale: The Suggested Data Cllectin Questin was simplified t decrease abstractin burden. Suggested Data Cllectin Questin What was the time at which a central venus pressure measurement btained? Central Venus Pressure Measurement Time Ratinale: The were updated t prvide guidance n the timeframe and hw t address if there are multiple assessments perfrmed. Page 25
Dcumentatin must ccur r reflect the assessment was perfrmed between Crystallid Fluid Administratin Date, Crystallid Fluid Administratin Time and six hurs after Septic Shck Presentatin Date, Septic Shck Presentatin Time. If there are multiple central venus pressure measurements perfrmed, abstract the time f the latest measurement dcumented within the allwable time windw. Central Venus Pressure measurement may be expressed as CVP, central venus pressure, r RAP, right atrial pressure. Clinical Trial Ratinale: The measure is being revised t exclude patients that are enrlled in a clinical trial related t sepsis care and management. Index Add: SEP-1 in Cllected Fr clumn fr Clinical Trial. Cllected Fr Add: Cllected Fr CMS Only: SEP-1 Change thrughut data element (i.e., VTE) T: (i.e., VTE r SEP-1) Add new sectin after VTE sectin: SEP-1: Only capture patients enrlled in clinical trials studying patients with sepsis, severe sepsis r septic shck (treatment and interventins). Crystallid Fluid Administratin Ratinale: The are being revised t list acceptable electrlytes that may be added t crystallid fluids t satisfy the 30 ml/kg infusin requirement. Add new secnd bullet pint: Crystallid fluid vlumes t which the fllwing electrlytes have been added may be cunted tward the 30 ml/kg requirement: ptassium, magnesium, calcium, lactate, acetate, r glucnate. Crystallid Fluid Administratin Ratinale: The Allwable Values were updated t clarify the target rdered vlume. Page 26
Allwable Values: Change frm: 1 (Yes) 30 ml/kg f crystallid fluids were rdered and initiated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, and 30 ml/kg f crystallid fluids were infused. 2 (N) Less than 30 ml/kg f crystallid fluids were rdered and initiated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine vlume rdered, r less than 30 ml/kg f crystallid fluids were infused. 3 (N) Crystallid fluids were nt initiated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine whether r nt they were administered. 4 (N) There is dcumentatin the patient has an implanted Ventricular Assist Device (VAD). T: 1 (Yes) Target rdered vlume f crystallid fluids were rdered, initiated, and infused prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck. 2 (N) Less than the target rdered vlume f crystallid fluids were rdered, initiated, r infused prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine vlume rdered. 3 (N) Crystallid fluids were nt initiated prir t, at the time f, r after the presentatin f Initial Hyptensin, Initial Lactate Level Result >=4 mml/l, r Dcumentatin f Septic Shck, r unable t determine whether r nt they were administered. 4 (N) There is dcumentatin the patient has an implanted Ventricular Assist Device (VAD) r dcumentatin f the patient r authrized patient advcate refusal f IV fluids. Crystallid Fluid Administratin Ratinale: The are being updated t prvide guidance and decrease abstractin burden. Crystallid fluid vlumes rdered that are equivalent t 30 ml/kg r within 10% less than 30 ml/kg are cnsidered the target rdered vlume. Crystallid fluid vlumes rdered that are within 10% lwer than the 30 ml/kg ttal vlume calculated by weight are acceptable. Example: 2000 ml f nrmal saline was rdered and initiated in the ED. The patient s weight is nt available r dcumented at the time f the rder. After admissin t critical care a weight is btained f 74 kg. Based n this weight 30 ml/kg is 2220 Page 27