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PC-04 Health Care-Associated Bloodstream Infections in Newborns

CBE ID
1731
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
1.3 Measure Description

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).

        • 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.

        • 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.

        • 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

        • Most Recent Endorsement Activity
          Measure Retired and Endorsement Removed Perinatal and Women's Health Spring Cycle 2020
          Initial Endorsement
          Last Updated
          Removal Date
        • Steward
          The Joint Commission
          Steward Organization POC Email
          Steward Organization Copyright

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