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Neonatal Blood Stream Infection Rate (NQI 03)

CBE ID
0478
1.4 Project
Perinatal and Women's Health
Endorsed
Endorsement Status
Endorsement Removed
1.1 New or Maintenance
Maintenance
E&M Cycle
Fall 2020
Is Under Review
No
1.3 Measure Description

Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.

    • 1.14 Numerator

      Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with either:
      • any secondary ICD-10-CM diagnosis codes for newborn sepsis (BSI5DX*), or
      • any secondary ICD-10-CM diagnosis codes for newborn septicemia or bacteremia codes requiring a separate organism code (BSI2DX*) and any secondary ICD-10-CM diagnosis codes for staphylococcal or Gram-negative bacterial infection (BSI3DX*)

    • 1.15 Denominator

      All newborns and outborns (Appendix I) with either:
      • a birth weight of 500 to 1,499 grams (Birth Weight Categories 2, 3, 4 and 5) (Appendix L)
      • any-listed ICD-10-CM diagnosis codes for gestational age between 24 and 30 weeks; (GESTCAT*)
      • a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and death (DISP=20)
      • a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and any-listed ICD-10-PCS procedure codes for operating room procedure (Appendix A)
      • a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and any-listed ICD-10-PCS procedure codes for mechanical ventilation (MECHVCD*)
      • a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and transferring from another health care facility within two days of birth (ATYPE = 4 and POINTOFORIGINUB04 = 6)

    • Exclusions

      Exclude cases:
      • with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for sepsis or bacteremia (BSI4DX*), among patients otherwise qualifying for numerator.
      • with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission†) for staphylococcal or Gram-negative bacterial infection (BSI3DX*), among patients otherwise qualifying for numerator.
      • with birth weight less than 500 grams (Birth Weight Category 1) (Appendix L)
      • with length of stay less than 3 days
      • with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

    • Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Perinatal and Women's Health Fall Cycle 2020
      Initial Endorsement
      Last Updated
      Removal Date