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.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.9 Care Setting1.20 Testing Data Sources
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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).
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1.15 Denominator
All selected surgical patients with no evidence of prior infection.
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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
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Most Recent Endorsement ActivityEndorsed with Reserve Status Surgery Endorsement Project 2013-2015Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
N/A
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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