Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations.
This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
Total number of observed healthcare-associated CLABSI among patients in bedded inpatient care locations.
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1.15 Denominator
Total number of predicted healthcare-associated CLABSI among patients in bedded inpatient care locations, calculated using the facility’s number of central line days and the following significant risk factors:
• Acute Care Hospitals: CDC location, facility bed size, medical school affiliation, facility type, birthweight category (NICU locations only)
• Critical Access Hospitals: no significant risk factors, calculation based intercept only model
• Inpatient Rehabilitation Facilities: Proportion of admissions with stroke, proportion of admissions in other non-specific diagnostic categories
• Long Term Acute Care Hospitals: CDC location type , facility bed size, average length of stay, proportion of admissions on a ventilator, proportion of admissions on hemodialysis
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Exclusions
Data from patients who are not assigned to an inpatient bed are excluded from the denominator counts, including outpatient clinics, 24-hour observation units, and emergency department visits. Inpatient rehab locations and inpatient psychiatric locations that have their own Centers for Medicare and Medicaid Services (CMS) Certification Number (CCN) are excluded.
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OLD 1.12 MAT output not attachedAttached1.13a Data dictionary not attachedNo
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Most Recent Endorsement ActivityEndorsed Patient Safety Spring Cycle 2019Initial EndorsementLast Updated
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StewardCenters for Disease Control and PreventionSteward Organization POC Email
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)
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