3 SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-9, SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Anesthesia End Time

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1 Release Notes: Alphabetical Data Dictionary Version 3.0b Surgical Care Improvement Project (SCIP) - Data Dictionary The General Abstraction Guidelines explain the different sections of the data element definitions and provide direction for common questions and issues that arise in medical record abstraction. Instructions in the specific data elements in this Data Dictionary should ALWAYS supersede those found in the General Abstraction Guidelines. Element Name Page # Collected For: Anesthesia End Date 3 SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-9, SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Anesthesia End Time 5 SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-10, SCIP-VTE- 1, SCIP-VTE-2 Anesthesia Start Date 8 ALL SCIP Measures, VTE-1², VTE-2² Anesthesia Start Time 10 SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Anesthesia Type 13 SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Antibiotic Administration Date 15 PN-3b, PN-52, PN-5c, PN-61, PN-6a2, PN-6b2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Antibiotic Administration Route 21 PN-61, PN-6a2, PN-6b2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Antibiotic Administration Time 27 PN-3b, PN-52, PN-5c, PN-61, PN-6a2, PN-6b2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Antibiotic Allergy 33 PN-61, PN-6a2, PN-6b2, SCIP-Inf-2 Antibiotic Name 35 PN-3b, PN-52, PN-5c, PN-61, PN-6a2, PN-6b2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Antibiotic Received 40 PN-3b, PN-52, PN-5c, PN-61, PN-6a2, PN-6b2, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Beta-Blocker Current Medication 43 SCIP-Card-2 Beta-Blocker During Pregnancy 45 SCIP-Card-2 Beta-Blocker Perioperative 46 SCIP-Card-2 Catheter Removed 48 SCIP-Inf-9 Clinical Trial 50 All AMI, CAC², HF, PN, PR², STK², VTE² Measures, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-1, SCIP-VTE-2 Comfort Measures Only 53 AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-92, AMI-T1a1 (Optional Test Measure), AMI-T21 (Optional Test Measure), All HF Measures, All PN Measures, STK-1², STK-2², STK-3², STK-5², STK-6², STK-8², STK-10², VTE-1², VTE-2², VTE-3², VTE-4², VTE-6² Date of Infection 56 SCIP-Inf-3 Glucose POD 1 58 SCIP-Inf-4 Glucose POD 2 61 SCIP-Inf-4 Infection Prior to Anesthesia 64 SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-9 Intentional Hypothermia 66 SCIP-Inf-10 Specifications Manual for National Hospital Inpatient Quality Measures 1

2 Element Name Page # Collected For: Joint Revision 68 SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Laparoscope 70 SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE- 1, SCIP-VTE-2 Measure Category Assignment 72 Used in the calculation of the Joint Commission s aggregate data and in the transmission of the Hospital Clinical Data file 2,3, ED-1 4, ED-2 4 Measurement Value 74 Used in the calculation of the Joint Commission s aggregate data Continuous Variable Measures (AMI-7, AMI-8, PN-5 2 ), and in the transmission of the Hospital Clinical Data file 2,3, ED-1 4, ED-2 4 Oral Antibiotics 76 SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Other Surgeries 78 SCIP-Inf-1, SCIP-Inf-3, SCIP-Inf-9 Perioperative Death 80 SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-1, SCIP-VTE-2 Postoperative Infections 82 SCIP-Inf-3 Preadmission Warfarin 84 SCIP-VTE-1, SCIP-VTE-2 Preoperative Hair Removal 86 SCIP-Inf-6 Reasons for Continuing Urinary 88 SCIP-Inf-9 Catheterization Reasons for Not administering Beta-Blocker - 90 SCIP Card 2 Perioperative Reason for Not administering VTE 93 SCIP-VTE-1, SCIP-VTE-2 Prophylaxis Sample 96 Used in transmission of the Joint Commission s aggregate data file and the Hospital Clinical Data file 3 Surgical Incision Time 97 SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Temperature 100 SCIP-Inf-10 Urinary Catheter 103 SCIP-Inf-9 Vancomycin 105 SCIP-Inf-2 VTE Prophylaxis 108 SCIP-VTE-1, SCIP-VTE-2, STK-1², VTE-1² VTE Timely 111 SCIP-VTE-2 1 CMS ONLY 2 The Joint Commission ONLY 3 Transmission Data Element 4 Informational ONLY Specifications Manual for National Hospital Inpatient Quality Measures 2

3 Release Notes: New Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Anesthesia End Date CMS/The Joint Commission: SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-9, SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 The date the anesthesia for the principal procedure ended. On what date did the anesthesia for the principal procedure end? Format: Length: 10 MM-DD-YYYY (includes dashes) or UTD Type: Date Occurs: 1 Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (2001-Current Year) UTD = Unable to Determine Notes for Abstraction: The Anesthesia End Date is the date associated with the anesthesia provider s sign-off after the principal procedure. This sign-off may occur after the patient leaves the operating area, in the post-anesthesia care area or intensive care unit. If the Anesthesia End Date cannot be determined from medical record documentation, enter UTD. When the date documented is obviously invalid (not a valid format/range [ xx] or before the Anesthesia Start Date) and no other documentation can be found that provides the correct information, the abstractor should select UTD. Example: o Patient expires on xx and documentation indicates the Anesthesia End Date was xx. Other documentation in the medical record supports the date of death as being accurate, but no other documentation of the Anesthesia End Date can be found. Since the Anesthesia End Date is outside of the parameter for care (after the Discharge Date [death]) and no other documentation is found, the abstractor should select UTD. If the Anesthesia End Date is obviously incorrect (in error) but it is a valid date and the correct date can be supported with other documentation in the medical record, the correct date may be entered. If supporting documentation of the correct date cannot be found, the medical record must be abstracted as documented Specifications Manual for National Hospital Inpatient Quality Measures 3

4 Notes for Abstraction continued: or at face value. Examples: o The anesthesia form is dated , but other documentation in the medical record supports that the correct date was Enter the correct date of as the Anesthesia End Date. o An Anesthesia End Date of xx is documented but the Anesthesia Start Date is documented as xx. Other documentation in the medical record supports the Anesthesia Start Date as being accurate. If no other documentation can be found to support another Anesthesia End Date, then it must be abstracted as xx because the date is not considered invalid or outside the parameter of care. Note: Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Anesthesia End Date allows the case to be accepted into the warehouse. Suggested Data Sources: Anesthesia record Circulation record/or nurses record Intraoperative record Operating room notes Guidelines for Abstraction: Inclusion None None Exclusion Specifications Manual for National Hospital Inpatient Quality Measures 4

5 Release Notes: New Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Anesthesia End Time CMS/The Joint Commission: SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 The time the anesthesia ended for the principal procedure. At what time did the anesthesia for the principal procedure end? Format: Length: 5 - HH:MM (with or without colon) or UTD Type: Time Occurs: 1 Allowable Values: HH = Hour (00-23) MM = Minutes (00-59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of Midnight and Noon: If the time is in the a.m., conversion is not required If the time is in the p.m., add 12 to the clock time hour Examples: Midnight = 00:00 Noon = 12:00 5:31 am = 05:31 5:31 pm = 17:31 11:59 am = 11:59 11:59 pm = 23:59 Note: 00:00 = midnight. If the time is documented as 00: xx, review supporting documentation to determine if the Anesthesia End Date should remain xx or if it should be converted to xx. When converting Midnight or 24:00 to 00:00, do not forget to change the Anesthesia End Date. Example: Midnight or 24:00 on xx = 00:00 on xx Notes for Abstraction: For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00 Specifications Manual for National Hospital Inpatient Quality Measures 5

6 Notes for Abstraction continued: The Anesthesia End Time is the time associated with the anesthesia provider s sign-off after the principal procedure. This sign-off may occur after the patient leaves the operating area, in the post-anesthesia care area or intensive care unit. If the Anesthesia End Time for the principal procedure cannot be determined from medical record documentation, enter UTD. When the time documented is obviously invalid (not a valid format/range [26:33] or before Anesthesia Start Time), and no other documentation is found that provides the correct information, the abstractor should select UTD. Example: o Anesthesia End Time is documented as 11:00 and Anesthesia Start Time is documented as 11:10. Other documentation supports the Anesthesia Start Time as being accurate, but no other documentation of the Anesthesia End Time can be found. Since the Anesthesia End Time is outside of the parameter for care (before the Anesthesia Start Time) and no other documentation is found, the abstractor should select UTD. If the Anesthesia End Time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be abstracted as documented or at face value. Examples: o The Anesthesia End Time is documented as 12:00, but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the Anesthesia End Time. o An Anesthesia End Time of 11:58 is documented but the Anesthesia Start Time is documented as 11:57. If no other documentation can be found to support another Anesthesia End Time, then it must be abstracted as 11:58 because the time is not considered invalid or outside the parameter of care. Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Anesthesia End Time allows the case to be accepted into the warehouse. If multiple procedures occur during the same surgical episode, the Anesthesia End Time captured will be the time associated with the anesthesia provider s sign-off after the surgical episode. If a patient leaves the operating room with an open incision (for closure at a later date/time), use the Anesthesia End Time Specifications Manual for National Hospital Inpatient Quality Measures 6

7 Notes for Abstraction continued: of the principal procedure. Do NOT use the date/time the patient returns to the OR for closure. Suggested Data Sources: Anesthesia record Circulation record Intraoperative record Operating room notes Post-anesthesia evaluation record Guidelines for Abstraction: Inclusion Anesthesia stop Anesthesia end None Exclusion Specifications Manual for National Hospital Inpatient Quality Measures 7

8 Release Notes: New Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Anesthesia Start Date CMS/The Joint Commission: All SCIP Measures, The Joint Commission Only: VTE-1, VTE-2 The date the anesthesia for the procedure started. On what date did the anesthesia for the procedure start? Format: Length: 10 MM-DD-YYYY (includes dashes) or UTD Type: Date Occurs: 1 Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (2001-Current Year) UTD = Unable to Determine Notes for Abstraction: SCIP: The Anesthesia Start Date is the date associated with the start of anesthesia for the principal procedure. If a patient enters the operating room, but the surgery is canceled before incision and the principal procedure is performed on a later date, the Anesthesia Start Date is the date the principal procedure was actually performed. VTE: The Anesthesia Start Date is the date associated with the start of anesthesia for the surgical procedure that was performed the day of or the day after hospital admission or ICU admission or transfer. If the patient had a procedure the day of and the day after hospital or ICU admission or transfer, select the last procedure that was performed using general or neuraxial anesthesia. NOTE: The VTE measures use Surgery End Date instead of Anesthesia End Date. If the Anesthesia Start Date cannot be determined from medical record documentation, enter UTD. When the date documented is obviously invalid (not a valid format/range [ xx] or after the Discharge Date or Anesthesia End Date) and no other documentation can be found that provides the correct information, the abstractor should select UTD. Example: Specifications Manual for National Hospital Inpatient Quality Measures 8

9 Notes for Abstraction continued: o Patient expires on xx and documentation indicates the Anesthesia Start Date was xx. Other documentation in the medical record supports the date of death as being accurate, but no other documentation of the Anesthesia Start Date can be found. Since the Anesthesia Start Date is outside of the parameter for care (after the Discharge Date [death]) and no other documentation is found, the abstractor should select UTD. If the Anesthesia Start Date is incorrect (in error) but it is a valid date and the correct date can be supported with other documentation in the medical record, the correct date may be entered. If supporting documentation of the correct date cannot be found, the medical record must be abstracted as documented or at face value. Examples: o The anesthesia form is dated , but other documentation in the medical record supports that the correct date was Enter the correct date of as the Anesthesia Start Date. o An Anesthesia End Date of xx is documented but the Anesthesia Start Date is documented as xx. If no other documentation can be found to support another Anesthesia Start Date, then it must be abstracted as xx because the date is not considered invalid or outside the parameter of care. Note: Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Anesthesia Start Date allows the case to be accepted into the warehouse. Suggested Data Sources: Anesthesia record Intraoperative record Operating room notes Guidelines for Abstraction: Inclusion None None Exclusion Specifications Manual for National Hospital Inpatient Quality Measures 9

10 Release Notes: New Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Anesthesia Start Time CMS/The Joint Commission: SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 The time the anesthesia was initiated for the principal procedure. At what time was the anesthesia initiated for the principal procedure? Format: Length: 5 - HH:MM (with or without colon) or UTD Type: Time Occurs: 1 Allowable Values: HH = Hour (00-23) MM = Minutes (00-59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of Midnight and Noon: If the time is in the a.m., conversion is not required If the time is in the p.m., add 12 to the clock time hour Examples: Midnight - 00:00 Noon - 12:00 5:31 am - 05:31 5:31 pm - 17:31 11:59 am - 11:59 11:59 pm - 23:59 Note: 00:00 = midnight. If the time is documented as 00: xx, review supporting documentation to determine if the Anesthesia End Date should remain xx or if it should be converted to xx. When converting Midnight or 24:00 to 00:00, do not forget to change the Anesthesia End Date. Example: Midnight or 24:00 on xx = 00:00 on xx Notes for Abstraction: For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00 Specifications Manual for National Hospital Inpatient Quality Measures 10

11 Notes for Abstraction continued: The Anesthesia Start Time is the time associated with the start of anesthesia for the principal procedure. If a patient enters the operating room, but the surgery is canceled before incision and the principal procedure is performed at a later time, the Anesthesia Start Time is the time the principal procedure was actually performed. If the Anesthesia Start Time cannot be determined from medical record documentation, enter UTD. When the time documented is obviously invalid (not a valid format/range [26:33] or after the Anesthesia End Time) and no other documentation is found that provides the correct information, the abstractor should select UTD. Example: o Anesthesia Start Time is documented as 14:00 and Anesthesia End Time is documented as 13:40. Other documentation in the medical record supports the Anesthesia End Time as being accurate, but no other documentation of the Anesthesia Start Time can be found. Since the Anesthesia Start Time is outside of the parameter for care (after the Anesthesia End Time) and no other documentation is found, the abstsractor should select UTD. If the Anesthesia Start Time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be abstracted as documented or at face value. Examples: o The Anesthesia Start Time is documented as 12:00, but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the Anesthesia Start Time. o An Anesthesia End Time of 11:58 is documented but the Anesthesia Start Time is documented as 11:57. If no other documentation can be found to support another Anesthesia Start Time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care. Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Anesthesia Start Time Specifications Manual for National Hospital Inpatient Quality Measures 11

12 Notes for Abstraction continued: allows the case to be accepted into the warehouse. If more than one Anesthesia Start Time is documented, use the earliest time documented. Suggested Data Sources: Anesthesia record Circulation record/ OR nurses record Intraoperative report Guidelines for Abstraction: Inclusion Anesthesia start Anesthesia begin Anesthesia initiated None Exclusion Specifications Manual for National Hospital Inpatient Quality Measures 12

13 Release Notes: New Data Element - Version 3.0a Data Element Name: Collected For: Definition: Suggested Data Collection Question: Anesthesia Type CMS/The Joint Commission: SCIP-Inf-10, SCIP-VTE-1, SCIP- VTE-2 Documentation that the procedure was performed using general or neuraxial anesthesia. General anesthesia is used to achieve a state of drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. General anesthesia may be achieved using agents administered by any route. Neuraxial anesthesia is used to achieve the loss of pain sensation with the administration of medication into the epidural space or spinal canal. Was there documentation that the procedure was performed using general or neuraxial anesthesia? Format: Length: 1 Type: Alphanumeric Occurs: 1 Allowable Values: 1 There is documentation that the procedure was performed using general anesthesia. 2 There is documentation that the procedure was performed using neuraxial anesthesia. 3 There is documentation that the procedure was performed using both neuraxial and general anesthesia. 4 There is no documentation that the procedure was performed using either general or neuraxial anesthesia or unable to determine from the medical record documentation. Notes for Abstraction: If there is documentation that the case was converted from a different type of anesthesia, such as a MAC, to a general or neuraxial anesthesia, select the appropriate value from the choices provided. If an attempt to use neuraxial anesthesia was unsuccessful and general anesthesia was used, select 3 because both methods were documented. Specifications Manual for National Hospital Inpatient Quality Measures 13

14 Suggested Data Sources: Anesthesia record Operative note Intraoperative Record PACU/recovery room record Procedure note Guidelines for Abstraction: Inclusion General Anesthesia o Inhaled Gases o Intravenous o Endotracheal o Laryngeal mask airway or anesthesia (LMA) Neuraxial Anesthesia o Spinal block o Epidural block o Spinal anesthesia o Subarachnoid blocks Exclusion Conscious sedation Monitored anesthesia care (MAC) Local with sedation Local with stand-by Peripheral nerve blocks Saddle block Deep sedation Specifications Manual for National Hospital Inpatient Quality Measures 14

15 Release Notes: Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Antibiotic Administration Date CMS/The Joint Commission: PN-3b, PN-5, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 The date (month, day, and year) for which an antibiotic dose was administered. An antibiotic may be defined as any drug, such as penicillin or streptomycin, containing any quantity of any chemical substance produced by a microorganism or made synthetically (i.e., quinolones) which has the capacity to inhibit the growth of or destroy bacteria and other microorganisms. Antibiotics are used in the prevention and treatment of infectious diseases. What was the date of administration for the antibiotic dose? Format: Length: 10 MM-DD-YYYY (includes dashes) or UTD Type: Date Occurs: 75 Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (2001 Current Year) UTD = Unable to Determine Notes for Abstraction: A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG and Other Cardiac Surgery] for SCIP-Inf) record the antibiotic name once for each route by which it was administered. Example: o A patient arrives at the hospital at 07:15 on XX. Zithromax IV is administered in the ED at 09:30 on XX. On XX at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax XX, 09:30, IV and Zithromax XX, 09:00, PO. Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic, enter an Antibiotic Administration Route, Date and Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, Specifications Manual for National Hospital Inpatient Quality Measures 15

16 Notes for Abstraction continued: utilize UTD for the missing information. Example: o The signed and dated anesthesia record contains the documentation: Ancef 1 gm at 10:50. The route is missing from this documentation. Enter UTD for the route in this grid entry. Do not use the operative report that contains documentation of the route to collect the missing information from the anesthesia record. Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic. Example: o Do not use physician orders as they do not demonstrate administration of the antibiotic (in the ED this may be used if signed/initialed by a nurse). The date or signature/initials documented on one side/page of a multi-sided or multi-paged form can be applied to all documentation on that form for abstraction purposes. If the date of administration is not documented on any side/page of the form, utilize "UTD" for the missing date. If the signature or initials signifying administration is not documented on any side/page of the form, that specific antibiotic cannot be abstracted. If an ED form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for ED documentation only. If this is not the case, utilize UTD for the missing date. If the date an antibiotic is administered is unable to be determined from medical record documentation, enter UTD. The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid format/range or outside of the parameter of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select UTD. Examples: o Documentation indicates the Antibiotic Administration Date was on XX. No other documentation in the medical record provides a valid date. Since the Antibiotic Administration Date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD. o Patient expires on XX and documentation indicates the Antibiotic Administration Date was XX. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date Specifications Manual for National Hospital Inpatient Quality Measures 16

17 Notes for Abstraction continued: (death), it is outside of the parameter of care and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above, will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Antibiotic Administration Date allows the case to be accepted into the warehouse. Collect only antibiotics administered via an appropriate route (SCIP-Inf: PO and IV; PN: PO, IV and IM) to answer this question. The use of hang time or infusion time is acceptable as antibiotic administration time when other documentation cannot be found. If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered. Only use Antibiotic NOS in the following situations: o For new antibiotics that are not yet listed in Table 2.1 o When there is documentation an antibiotic was administered but unable to identify the name. It must be apparent that the medication is an antibiotic. Example: On XX, the ED record contains the documentation, Antibiotic started name illegible, 2gm, IV, 0200-JM. In the antibiotic grid, Antibiotic NOS would be entered for the name, IV for the route, 0200 for the time and XX for the date. (If Antibiotic started had not been documented in this example, the medication could not be abstracted as an Antibiotic Received. Do not collect antibiotics documented on the operative report as this does not reflect actual administration. Notes for Abstraction continued: SCIP-Inf: First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Anesthesia End Time (72 hours postop for CABG or Other Cardiac Surgery). Second: Abstract the dose administered prior and closest to Surgical Incision Time. Example: o Arrival Time was 07:00. Surgical Incision Time was 12:00. Anesthesia End Time was 14:00. Antibiotic A was Specifications Manual for National Hospital Inpatient Quality Measures 17

18 administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered at 15:30 and 17:00. Abstract: - Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last) - Antibiotic B: 15:30 (first) and 17:00 (last) Notes: This data element has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery). However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable. In addition to abstracting the specific doses with non-utd values for Antibiotic Administration Time or Antibiotic Administration Date that satisfy the requirements for either of the approaches for abstraction: 1. All doses documented without a date should be abstracted with UTD for Antibiotic Administration Date as it can t be determined if the dose(s) falls into the guidelines for either of these approaches. 2. All doses documented without a time but with a non- UTD Antibiotic Administration Date should be abstracted with UTD Antibiotic Administration Time if you are unable to determine if the dose(s) falls into the guidelines for either of these approaches. Example: o Anesthesia Start Date was XX. Arrival Time was 07:00. Surgical Incision Time was 12:00. Anesthesia End Time was 14:00. Antibiotic A was administered XX at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered XX at 11:00 and also XX without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date. Abstract the doses administered at the following times: Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last) Antibiotic B: 11:00 (first) and UTD (without an administration time it can t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose) Specifications Manual for National Hospital Inpatient Quality Measures 18

19 Notes for Abstraction continued: Notes for Abstraction continued: Antibiotic C: 11:30 (without an administration date, it can t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose) PN: Document the initial (first time) month, day, and year, for which the patient received each antibiotic administered during the first 24 hours after hospital arrival. If an antibiotic is given more than one time during the first 24 hours after hospital arrival, only record the antibiotic name once. Enter the first administration date and time associated with each antibiotic name. Note: In addition to abstracting the specific doses with non-utd values for Antibiotic Administration Time or Antibiotic Administration Date that were administered within the first 24 hours after hospital arrival: 1. All doses documented without a date should be abstracted with UTD for Antibiotic Administration Date as it can t be determined if the dose(s) were administered within the first 24 hours after hospital arrival. 2. All doses documented without a time but with a non-utd Antibiotic Administration Date should be abstracted with UTD Antibiotic Administration Time if you are unable to determine if the dose(s) were administered within the first 24 hours after hospital arrival. Example: o Arrival Date was XX. Arrival Time was 06:00. Antibiotic A was administered XX at 08:00, 14:00, and 22:00. Antibiotic B was administered XX without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date, and XX at 09:00. Abstract the doses administered at the following times: Antibiotic A: 08:00 (first dose within 24 hours after arrival) Antibiotic B: UTD (without an administration time, it can t be determined if this dose was within the first 24 hours after arrival) Antibiotic C: 11:30 (without an administration date, it can t be determined if this dose was within the first 24 hours after arrival) Specifications Manual for National Hospital Inpatient Quality Measures 19

20 Suggested Data Sources: Emergency department record ICU flowsheet IV flowsheet Medication administration record Nursing notes Perfusion record For SCIP-Inf, in addition to the above suggested data sources, the following may also be utilized: Anesthesia record Operating room record PACU/recovery room record Guidelines for Abstraction: Inclusion None None Exclusion Specifications Manual for National Hospital Inpatient Quality Measures 20

21 Release Notes: Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Antibiotic Administration Route CMS/The Joint Commission: PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Method of administration of a dose of medication. Medications may be administered in a variety of ways depending upon how they are supplied and prescribed. Methods of administration are listed below as allowable values. What was the route of administration for the antibiotic dose? Format: Length: 2 Type: Alphanumeric Occurs: 75 Allowable Values: 1 PO/NG/PEG tube (Oral) 2 IV (Intravenous) 3 IM (Intramuscular) 10 UTD Notes for Abstraction: A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf) record the antibiotic name once for each route by which it was administered. Example: o A patient arrives at the hospital at 07:15 on XX. Zithromax IV is administered in the ED at 09:30 on XX. On XX at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax XX, 09:30, IV and Zithromax XX, 09:00, PO. Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic name, enter an Antibiotic Administration Route, Specifications Manual for National Hospital Inpatient Quality Measures 21

22 Notes for Abstraction continued: Notes for Abstraction Date, and Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilize UTD for the missing information. Example: o The signed and dated anesthesia record contains the documentation: Ancef 1 gm at 10:50. The route is missing from this documentation. Enter UTD for the route in this grid entry. Do not use the operative report that contains documentation of the route to collect the missing information from the anesthesia record. Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic. Example: o Do not use physician orders as they do not demonstrate administration of the antibiotic (in the ED this may be used if signed/initialed by a nurse). The date or signature/initials documented on one side/page of a multi-sided or multi-paged form can be applied to all documentation on that form for abstraction purposes. If the date of administration is not documented on any side/page of the form, utilize "UTD" for the missing date. If the signature or initials signifying administration is not documented on any side/page of the form, that specific antibiotic cannot be abstracted. If an ED form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for ED documentation only. If this is not the case, utilize UTD for the missing date. Collect only antibiotics administered via an appropriate route (SCIP-Inf: PO and IV; PN: PO, IV and IM) or UTD to answer this question. Allowable Values 4, 5, 6, 7, 8 & 9 were retired and may no longer be abstracted effective with discharges. The use of hang time or infusion time is acceptable as antibiotic administration time when other documentation cannot be found. If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered. Only use Antibiotic NOS in the following situations: o For new antibiotics that are not yet listed in Table 2.1 o When there is documentation an antibiotic was administered but unable to identify the name. It must be Specifications Manual for National Hospital Inpatient Quality Measures 22

23 continued: apparent that the medication is an antibiotic. Example: On XX, the ED record contains the documentation Antibiotic started name illegible, 2gm, IV, 0200-HF. In the antibiotic grid, Antibiotic NOS would be entered for the name, IV for the route, 0200 for the time and XX for the date. (If Antibiotic started had not been documented in this example, the medication could not be abstracted as an Antibiotic Received.) Do not collect antibiotics documented on the operative report as this does not reflect actual administration. Notes for Abstraction continued: SCIP-Inf: First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Anesthesia End Time (72 hours postop for CABG or Other Cardiac Surgery). Second: Abstract the dose administered prior and closest to Surgical Incision Time. Example: o Arrival Time was 07:00. Surgical Incision Time was 12:00. Anesthesia End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered at 15:30 and 17:00. Abstract: - Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last) - Antibiotic B: 15:30 (first) and 17:00 (last) Notes: This data element has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery). However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable. In addition to abstracting the specific doses with non-utd values for Antibiotic Administration Time or Antibiotic Administration Date that satisfy the requirements for either of the approaches for abstraction: 1. All doses documented without a date should be abstracted with UTD for Antibiotic Administration Date as it can t be determined if the dose(s) falls into the guidelines for either of these approaches. Specifications Manual for National Hospital Inpatient Quality Measures 23

24 2. All doses documented without a time but with a non- UTD Antibiotic Administration Date should be abstracted with UTD Antibiotic Administration Time if you are unable to determine if the dose(s) falls into the guidelines for either of these approaches. Example: o Anesthesia Start Date was XX. Arrival Time was 07:00. Surgical Incision Time was 12:00. Anesthesia End Time was 14:00. Antibiotic A was administered XX at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered XX at 11:00 and also XX without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date. Abstract the doses administered at the following times: Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last) Antibiotic B: 11:00 (first) and UTD (without an Administration time it can t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose) Antibiotic C: 11:30 (without an administration date, it can t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose) Notes for Abstraction continued: PN: Document the route of administration for the initial start date and time of each antibiotic administered during the first 24 hours after hospital arrival. If an antibiotic is administered more than once by the same route during the first 24 hours after hospital arrival, only record the antibiotic name once. Enter the first administration date, time, and route associated with each antibiotic name. Note: In addition to abstracting the specific doses with non-utd values for Antibiotic Administration Time or Antibiotic Administration Date that were administered within the first 24 hours after hospital arrival: 1. All doses documented without a date should be abstracted with UTD for Antibiotic Administration Date as it can t be determined if the dose(s) were administered within the first 24 hours after hospital arrival. 2. All doses documented without a time but with a non-utd Antibiotic Administration Date should be abstracted with UTD Antibiotic Administration Time if you are unable to Specifications Manual for National Hospital Inpatient Quality Measures 24

25 determine if the dose(s) were administered within the first 24 hours after hospital arrival. Example: o Arrival Date was XX. Arrival Time was 06:00. Antibiotic A was administered XX at 08:00, 14:00, and 22:00. Antibiotic B was administered XX without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date, and XX at 09:00. Abstract the doses administered at the following times: Antibiotic A: 08:00 (first dose within 24 hours after arrival) Antibiotic B: UTD (without an administration time, it can t be determined if this dose was within the first 24 hours after arrival) Antibiotic C: 11:30 (without an administration date, it can t be determined if this dose was within the first 24 hours after arrival) Suggested Data Sources: Emergency department record ICU flowsheet IV flowsheet Medication administration record Nursing notes Perfusion record For SCIP-Inf, in addition to the above suggested data sources, the following may also be utilized: Anesthesia record Operating room record PACU/recovery room record Guidelines for Abstraction: Inclusion Include any antibiotics given: Intravenous: Bolus Infusion IV I.V. IVPB IV piggyback Parenteral Perfusion Exclusion Abdominal irrigation Chest irrigation Eardrops Enema/rectally Eyedrops Inhalation Intracoronary Joint irrigation Mixed in cement Mouthwash Specifications Manual for National Hospital Inpatient Quality Measures 25

26 PO/NG/PEG tube: Any kind of feeding tube (e.g., percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, gastrostomy tube) By mouth Gastric tube G-tube Jejunostomy J-tube Nasogastric tube PO P.O. Nasal sprays Peritoneal dialysate (antibiotic added to) Peritoneal irrigation Swish and spit Swish and swallow (S/S) Topical antibiotics Troches Vaginal administration Wound irrigation For PN, in addition to the above routes, also include any antibiotics given: Intramuscular: Injected IM I.M. Z-track Refer to Appendix C, Table 2.1 for a comprehensive list of Antimicrobial Medications. Specifications Manual for National Hospital Inpatient Quality Measures 26

27 Release Notes: Data Element - Version 3.0 Data Element Name: Collected For: Definition: Suggested Data Collection Question: Antibiotic Administration Time CMS/The Joint Commission: PN-3b, PN-5, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 The time (military time) for which an antibiotic dose was administered. What was the time of administration for the antibiotic dose? Format: Length: 5 HH:MM (with or without colon) or UTD Type: Time Occurs: 75 Allowable Values: HH = Hour (00-23) MM = Minutes (00-59) UTD = Unable to Determine Time must be recorded in military time format. With the exception of Midnight and Noon: If the time is in the a.m., conversion is not required. If the time is in the p.m., add 12 to the clock time hour. Examples: Midnight - 00:00 Noon - 12:00 5:31 am - 05:31 5:31 pm - 17:31 11:59 am - 11:59 11:59 pm - 23:59 Note: 00:00 = midnight. If the time is documented as 00: XX, review supporting documentation to determine if the Antibiotic Administration Date should remain XX or if it should be converted to XX. When converting Midnight or 24:00 to 00:00 do not forget to change the Antibiotic Administration Date. Example: Midnight or 24:00 on XX= 00:00 on XX Notes for Abstraction: For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00 A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade Specifications Manual for National Hospital Inpatient Quality Measures 27

28 Notes for Abstraction continued: names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf) record the antibiotic name once for each route by which it was administered. Example: o A patient arrives at the hospital at 07:15 on XX. Zithromax IV is administered in the ED at 09:30 on XX. On at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax XX, 09:30, IV and Zithromax XX, 09:00, PO. Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic name, enter an Antibiotic Administration Route, Date, and Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilize UTD for the missing information. Example: The signed and dated anesthesia record contains the documentation: Ancef 1 gm at 10:50. The route is missing from this documentation. Enter UTD for the route in this grid entry. Do not use the operative report that contains documentation of the route to collect the missing information from the anesthesia record. The use of hang time or infusion time is acceptable as antibiotic administration time when other documentation cannot be found. Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic. Example: o Do not use physician orders as they do not demonstrate administration of the antibiotic (in the ED this may be used if signed/initialed by a nurse). The date or signature/initials documented on one side/page of a multi-sided or multi-paged form can be applied to all documentation on that form for abstraction purposes. If the date of administration is not documented on any side/page of the form, utilize "UTD" for the missing date. If the signature or initials signifying administration is not documented on any side/page of the form, that specific antibiotic cannot be abstracted. If an ED form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for ED documentation only. If this is not the case, utilize UTD for the missing date. Specifications Manual for National Hospital Inpatient Quality Measures 28

29 Notes for Abstraction continued: If the time an antibiotic is administered is unable to be determined from medical record documentation, enter UTD. If collecting the time for an antibiotic administered via infusion (IV) the Antibiotic Administration Time refers to the time the antibiotic infusion was started. The medical record must be abstracted as documented (taken at face value ). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD. Example: o Documentation indicates the Antibiotic Administration Time was No other documentation in the medical record provides a valid time. Since the Antibiotic Administration Time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD. Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Antibiotic Administration Time allows the case to be accepted into the warehouse. Collect only antibiotics administered via an appropriate route (SCIP-Inf: PO and IV; PN: PO, IV and IM) to answer this question. If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered. Only use Antibiotic NOS in the following situations: o For new antibiotics that are not yet listed in Table 2.1 o When there is documentation an antibiotic was administered but unable to identify the name. It must be apparent that the medication is an antibiotic. Example: On XX, the ED record contains the documentation Antibiotic started, name illegible, 2gm, IV, 0200-HF. In the antibiotic grid, Antibiotic NOS would be entered for the name, IV for the route, 0200 for the time and XX for the date. (If Antibiotic started had not been documented in this example, the medication could not be abstracted as an Antibiotic Received. Do not collect antibiotics documented on the operative report as this does not reflect actual administration. Specifications Manual for National Hospital Inpatient Quality Measures 29