Inappropriately Broad Empiric Antibiotic Selection for Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Laboratory Test, Performed": "Blood Urea Nitrogen"] BUN
            such that BUN.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and BUN.result as Quantity >= 20 'mg/dL'

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        where exists (["Laboratory Test, Performed": "Complete Blood Count (with Diff)"] CellCount
            where CellCount.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and exists CellCount.components Component
                    where Component.code = "Platelets [#/volume] in Blood"
                        and Component.result is not null
                        and Component.result as Quantity < 100000 '{Cells}/uL')

    "Relevant Comorbidities"
        union "Neutropenia"
        union "History of Transplant"

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with Encounter.diagnoses ConcurrentDx
            such that ConcurrentDx.code in "CAP Concurrent Infections"

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Patient Characteristic Expired": "Dead (finding)"] Deceased
            such that Deceased.expiredDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Physical Exam, Performed": "Oxygen Saturation in Blood"] OxygenSat
            such that OxygenSat.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and OxygenSat.result as Quantity < 90 '%'

    "Initial Population"

    "Complex CAP Encounter"
        union "Risk Factors for MRSA/PSA"

    "Deceased in 48 Hours"
        union "ICU Admission"
        union "Transfer In"
        union "Concurrent Infection"

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Physical Exam, Performed": "Inhaled oxygen flow rate"] Inhalation
            such that Inhalation.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and Inhalation.result as Quantity >= 5 'L/min'

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Physical Exam, Performed": "Respiratory Rate"] RespRate
            such that RespRate.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and RespRate.result as Quantity > 30 '{breaths}/min'

    ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
        with ["Diagnostic Study, Performed": "Chest Imaging for Pneumonia Grouping Definition"] ChestImaging
            such that ChestImaging.authorDatetime during Interval [start of InpatientEncounter.relevantPeriod -72 hours, end of InpatientEncounter.relevantPeriod + 72 hours]
                and ChestImaging.authorDatetime during day of "Measurement Period"

    "Qualifying CAP Encounter" QCAPEncounter
        with ["Procedure, Performed": "Major Transplant"] Transplant
            such that Transplant.relevantPeriod ends during day of Interval[start of QCAPEncounter.relevantPeriod - 365 days, start of QCAPEncounter.relevantPeriod]

    ["Encounter, Performed": "Encounter Inpatient"] Encounter   
        where exists Encounter.facilityLocations Location
            where Location.code in "Intensive Care Unit"
                and Location.locationPeriod starts during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]

    "MDRO Antibiotics"
        union "IV Vancomycin"

    "Qualifying CAP Encounter for Patient with Appropriate Age"

    "Qualifying CAP Encounter" QCAPEncounter
        with ["Medication, Administered": "vancomycin"] Vanc
            such that Vanc.route in "Intravenous Medication Route"

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        where exists (["Laboratory Test, Performed": "Complete Blood Count (with Diff)"] CellCount
            where CellCount.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and exists CellCount.components Component
                    where Component.code = "Leukocytes [#/volume] in Blood"
                        and Component.result is not null
                        and Component.result as Quantity < 4000 '{Cells}/uL')

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Physical Exam, Performed": "Body Temperature"] BodyTemp
            such that BodyTemp.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and BodyTemp.result as Quantity < 36 'Cel'
                    or BodyTemp.result as Quantity < 96.8 '[degF]'

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        with ["Physical Exam, Performed": "Systolic Blood Pressure"] SystolicBP
            such that SystolicBP.relevantDatetime during Interval[start of Encounter.relevantPeriod, start of Encounter.relevantPeriod + 48 hours]
                and SystolicBP.result as Quantity < 80 'mm[Hg]'

    "Qualifying CAP Encounter" QCAPEncounter
        with ["Medication, Administered": "Broad Spectrum Antibiotics for MDRO"] MDROabx
            such that MDROabx.relevantPeriod overlaps Interval[start of QCAPEncounter.relevantPeriod, start of QCAPEncounter.relevantPeriod + 48 hours]

   "Qualifying CAP Encounter" QCAPEncounter
        where exists (["Laboratory Test, Performed": "Complete Blood Count (with Diff)"] BloodTest
            where exists BloodTest.components Component
                where Component.code = "Neutrophils [#/volume] in Blood"
                    and Component.result is not null
                    and Component.result as Quantity < 500 '{Cells}/uL')

    "Inappropriately Broad Empiric Antibiotic Selection"

    exists ("Qualifying CAP Encounter" QCAPEncounter
        where(
            exists(["Encounter, Performed": "Encounter Inpatient"] PriorHospitalization
                where PriorHospitalization.relevantPeriod overlaps Interval[start of QCAPEncounter.relevantPeriod - 3 months, start of QCAPEncounter.relevantPeriod]
                    and exists ["Medication, Administered": "Antibiotic Usage for CAP Diagnosis"] Antibiotic
                        where Antibiotic.authorDatetime during Interval[start of QCAPEncounter.relevantPeriod - 3 months, start of QCAPEncounter.relevantPeriod]
                            and Antibiotic.route in "Intravenous Medication Route")))

    "Qualifying Encounter" QEncounter
        where exists (QEncounter.diagnoses Diagnosis
            where Diagnosis.code in "CAP, Sepsis, Respiratory Failure Diagnostic")

    "Qualifying CAP Encounter" QCAPEncounter
        where QCAPEncounter.relevantPeriod ends during day of "Measurement Period"
            and AgeInYearsAt(date from start of QCAPEncounter.relevantPeriod) >= 18

    ["Encounter, Performed": "Encounter Inpatient"] QCAPEncounter
        where exists (["Medication, Administered": "Antibiotic Usage for CAP Diagnosis"] Antibiotic
            where Antibiotic.authorDatetime during Interval[start of QCAPEncounter.relevantPeriod, start of QCAPEncounter.relevantPeriod + 48 hours])
        and exists "Encounter with Chest Imaging during Hospitalization" ChestImagingEnc
            where ChestImagingEnc.id = QCAPEncounter.id
        and not exists "Disqualifying Encounter Elements" dqEncounter
            where dqEncounter.id = QCAPEncounter.id

    "Qualifying CAP Encounter" QCAPEncounter        
        with QCAPEncounter.diagnoses EncounterDiagnoses
            such that EncounterDiagnoses.code in "Comorbidities Indicated with CAP"
                or EncounterDiagnoses.code = "Human immunodeficiency virus [HIV] disease"
                or EncounterDiagnoses.code = "Patient immunocompromised (finding)"

    "Secondary Infection"
       union "Severe CAP with Prior Hospitalization"

    ["Patient Characteristic Ethnicity": "Ethnicity"]

    ["Patient Characteristic Payer": "Payer Type"]

    ["Patient Characteristic Race": "Race"]

    ["Patient Characteristic Sex": "ONC Administrative Sex"]

    "Qualifying CAP Encounter" QCAPEncounter
        with ["Laboratory Test, Performed": "Bacteria identified in Specimen by Respiratory culture"] RespCulture
            such that RespCulture.authorDatetime during Interval[start of QCAPEncounter.relevantPeriod - 365 days, start of QCAPEncounter.relevantPeriod]
                and RespCulture.result.code in "Pseudomonas aeruginosa (Organism or Substance in Lab Results)"
                    or RespCulture.result.code in "MRSA (Disorders (SNOMED)"

"Qualifying CAP Encounter" QCAPEncounter
    where (
        (if exists ("Elevated Respiration" ER where ER.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Elevated Inhaled Oxygen" EIO where EIO.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Decreased Oxygen Saturation" DOS where DOS.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Leukopenia" LKP where LKP.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Abnormal Platelet" AP where AP.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Abnormal BUN" ABUN where ABUN.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Low Body Temp" LBT where LBT.id = QCAPEncounter.id) then 1 else 0)
        + (if exists ("Low SBP" LSBP where LSBP.id = QCAPEncounter.id) then 1 else 0)
    ) >= 2
    and "Prior Hospitalization with IV Antibiotic" is true

    ["Encounter, Performed": "Encounter Inpatient"] Encounter
        where exists ["Procedure, Performed": "Hospital admission, transfer from other hospital or health care facility (procedure)"] TransferIn