This measure assesses the number of staphylococcal and gram negative septicemias or bacteremias in high-risk newborns. This measure is a part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-03: Antenatal Steroids, PC-05: Exclusive Breast Milk Feeding; Beginning 1/1/2019 PC-06 Unexpected Complications in Term Newborns will be added).
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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
The outcome being measured is: Newborns with septicemia or bacteremia with ICD-10-CM Other Diagnosis Codes for newborn septicemia or bacteremia as defined in Appendix A, Table 11.10 with a Bloodstream Infection Confirmed OR ICD- 10-CM Other Diagnosis Codes for sepsis as defined in Appendix A, Table 11.10.1 with a Bloodstream Infection Confirmed.
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1.15 Denominator
The outcome target population being measured is: Liveborn newborns with ICD-10-CM Other Diagnosis Codes for birth weight between 500 and 1499g as defined in Appendix A, Table 11.12, 11.13 or 11.14 OR Birth Weight between 500 and 1499g OR ICD-10-CM Other Diagnosis Codes for birth weight = > 1500g as defined in Appendix A, Table 11.15 or 11.16 OR Birth Weight = > 1500g who experienced one or more of the following:
o Experienced death
o ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for major surgery as defined in Appendix A, Table 11.18
o ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for mechanical ventilation as defined in Appendix A, Table 11.19
o Transferred in from another acute care hospital or health care setting within 2 days of birth.
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Exclusions
• ICD-10-CM Principal Diagnosis Code for septicemias or bacteremias as defined in Appendix A, Table 11.10.2
• ICD-10-CM Other Diagnosis Codes for septicemias or bacteremias as defined in Appendix A, Table 11.10.2 or ICD-10-CM Principal or Other Diagnosis Codes for newborn septicemia or bacteremia as defined in Appendix A, Table 11.10 with a Bloodstream Infection Present on Admission
• ICD-10-CM Other Diagnosis Codes for birth weight < 500g as defined in Appendix A, Table 11.20 OR Birth Weight < 500g
• Length of Stay < 2 days
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Perinatal and Women's Health Spring Cycle 2020Initial EndorsementLast UpdatedRemoval Date
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StewardThe Joint CommissionSteward Organization POC EmailSteward Organization Copyright
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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Planned Use
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