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.
- Measure TypeElectronic Clinical Quality Measure (eCQM)Care SettingNumerator
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).
DenominatorAll selected surgical patients with no evidence of prior infection.
ExclusionsExcluded 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 stayTesting Data Sources
- Measure StructureClinical Condition Topic AreaNon Condition SpecificTarget PopulationNational Quality Strategy PrioritiesPatient Safety
- Risk Adjustment
- Current or planned use(s)Current Use(s)
- Most Recent Endorsement ActivityEndorsed with Reserve Status Surgery Endorsement Project 2013-2015Initial EndorsementEndorsement StatusLast Updated
- Steward Organization EmailSteward Organization Copyright
N/A