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Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

CBE ID
0527
1.4 Project
Endorsement Status
Previous Endorsement Cycle
Is Under Review
No
1.3 Measure Description

Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

        • 1.14 Numerator

          Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if receiving vancomycin, in Appendix C, Table 3.8, or a fluoroquinolone, in Appendix C, Table 3.10).

        • 1.15 Denominator

          All selected surgical patients with no evidence of prior infection.

        • Exclusions

          Excluded Populations:
          • Patients less than 18 years of age
          • Patients who have a length of stay greater than 120 days
          • Patients whose Principal Procedure was on Table 5.25
          • Patients who had a hysterectomy and a caesarean section performed during this hospitalization
          • Patients who had a principal diagnosis suggestive of preoperative infectious diseases (as defined in Appendix A, Table 5.09 for ICD-9-CM codes)
          • Patients enrolled in clinical trials
          • Patients whose ICD-9-CM principal procedure occurred prior to the date of admission
          • Patients with physician/advanced practice nurse/physician assistant (physician/APN/PA) documented infection prior to surgical procedure of interest
          • Patients who had other procedures requiring general or spinal anesthesia that occurred within 3 days (4 days for CABG or Other Cardiac Surgery) prior to or after the procedure of interest (during separate surgical episodes) during this hospital stay

        • Most Recent Endorsement Activity
          Endorsed with Reserve Status Surgery Endorsement Project 2013-2015
          Initial Endorsement
          Last Updated
        • Steward
          Centers for Medicare & Medicaid Services
          Steward Organization POC Email
          Steward Organization Copyright

          N/A