Chapter 3701-14 DRG Reporting Requirements

3701-14-01 Definitions and DRG reporting requirements.

(A) As used in this rule:

(1) "ADRG" means the adjacent diagnosis-related groups as defined by the DRG refinement system.

(2) "DRG" or "DRGs" means the diagnosis-related group or groups that a hospital assigns based upon the clinical record of the patient for the purpose of classifying inpatient hospital services and determining reimbursement for services performed.

(3) "Charge outlier case" means a patient discharged from the hospital whose total charges are equal to or greater than the charge trim point for that patient's DRG.

(4) "Charge trim point" means two standard deviations above the arithmetic mean of charges for all cases in a DRG.

(5) "Day outlier case" means a patient discharged from the hospital whose total number of inpatient days are equal to or greater than the length of stay trim point for that patient's DRG.

(6) "DRG refinement system" means the severity of illness classification system developed by the "Health Systems Management Group, School of Management, Yale University," as updated by the director of health.

(7) "HSMG refinement grouper" means of the software which implements the DRG refinement system, as updated by the director of health for discharges on or after October first of each year.

(8) "Hospital" means an institution classified and registered as a hospital under section 3701.07 of the Revised Code.

(9) "ICD-9-CM procedure code" means an identifier assigned to describe the medical procedure used for the treatment of illness and injury.

(10) "Length of stay trim point" means two standard deviations above the arithmetic mean of the length of stay for all cases in a DRG.

(11) "LOS" or "length of stay" means the number of days a patient is in the hospital per admission as calculated by counting the number of days from and including the day of admission up to but not including the day of discharge.

(12) "Mean" means the arithmetic average that is calculated by adding the values and dividing by the number of cases.

(13) "Median" means the middle case where fifty per cent of the cases have lower values and fifty per cent of the cases have higher values.

(14) "Outpatient procedure" means a non-urgent medical procedure performed on an outpatient basis in a hospital under the supervision of a physician for the diagnosis or treatment of a disease or other disorder. "Outpatient procedure" does not include procedures performed in clinics or other settings where only ancillary services are provided or where physician services are not typically provided, such as radiology, laboratory services, physical rehabilitation, renal dialysis, or pharmacy.

(15) "Range" means the lowest and the highest values.

(16) "Refinement class" means the severity level within each ADRG, as defined by the DRG refinement system and HSMG refinement grouper, in which a patient may be classified based on the extent that a patient's illness involves multiple complications and comorbid conditions requiring a certain degree of complexity in treatment and diagnosis.

(17) "Refinement group number" or "RGN" means the complete four-digit number assigned by the HSMG refinement grouper which consists of the ADRG code number in character positions one through three and the refinement class code number in character position four.

(18) "Trim points" mean charge trim point and length of stay trim point.

(19) "Primary procedure code" means the code that identifies the principal procedure performed during the period covered by a bill and the date on which the principal procedure described on the bill was performed.

(B) On or before the first day of May each year, every hospital shall disclose to the director of health the following inpatient data:

(1) The total number of patients in each of the sixty DRGs most frequently treated on an inpatient basis in the hospital as represented by discharges during the previous calendar year and based upon the DRG grouper in effect on the first day of October of the calendar year preceding the calendar year which the patient was discharged. If DRG 468, 469, or 470 appears on the list of most frequently treated DRGs, the DRG or DRGs shall be removed from the list and the next most frequently treated DRG or DRGs shall be substituted in its place:

(a) The total number of patients discharged;

(b) The mean, median, and range of total hospital charges;

(c) The mean, median, and range of length of stay;

(d) The number of admissions from each of the following:

(i) Emergency room: For the purposes of this provision, "admissions from emergency room" means the number of patients admitted to the hospital through the emergency room upon the recommendation of a physician;

(ii) Transfer from another hospital;

(iii) Other sources of admission including, but not limited to, skilled nursing facilities or health care facilities other than an acute care hospital; referrals from a personal physician, clinic physician, health maintenance organization, a court of law; a newborn if the patient was born in the facility; and those admissions for which information is not available;

(e) The number of cases, mean charges, and mean length of stay in each refinement class or refinement group number excluding all charge outlier cases and day outlier cases based on the trim points provided and published by the director at least one hundred twenty days prior to May first each year; and

(2) The number of patients falling within DRG numbers 468, 469, and 470.

Paragraphs (B)(1)(a) to (B)(1)(d) of this rule do not require the disclosure of data for any DRG for which the hospital treated fewer than ten patients during the year. Paragraph (B)(1)(e) of this rule does not require the disclosure of data for any refinement group number for which the hospital treated less than three patients during the year.

(C) On or before the first day of May each year, every hospital shall disclose to the director of health the following outpatient data:

(1) The total number of patients in each of the sixty most frequently performed outpatient primary procedures in the hospital as reported by ICD-9-CM primary procedure codes for patients treated during the previous calendar year.

(2) The mean and median of the total hospital charges for those sixty most frequently performed outpatient procedures identified in paragraph (C)(1) of this rule.

(3) The hospital is not required to disclose data for any procedure for which the hospital treated fewer than ten patients during the year.

(D) Each hospital shall:

(1) Submit the hospital identification and certification form, prescribed in appendix A of this rule, signed by the chief executive officer of the hospital;

(2) Submit the inpatient data required to be reported under this rule to the director in an electronic format as provided in appendix B of this rule, or in a paper format as provided in appendix C to this rule, and report the DRG data required by paragraph (B)(1) of this rule in descending order according to the frequency of admissions with the DRG having the most frequent number of admissions reported first;

(3) Submit the outpatient data required to be reported under this rule to the director in an electronic format as provided in appendix D to this rule and report the procedure data required by paragraph (C) of this rule in descending order according to the frequency of patients with the procedure having the most frequent number of patients reported first.

(E) Each hospital may include with the data disclosed under this rule commentary concerning reasons for major deviations in the range of data for any DRG. The hospital shall submit the commentary in the format prescribed by appendix C to this rule. Any release of the data disclosed under this rule identifying a hospital shall include the commentary, if any, submitted by the hospital pursuant to this paragraph.

(F) Any releases by the department of information collected pursuant to section 3727.34 of the Revised Code that list charge data by hospital shall include conspicuous language explaining that the data in the report either has been reported by severity of illness or adjusted with respect to the severity of illness of the patients and that an individual hospital's average charges may differ significantly from the average charges of a group of hospitals because of a variety of reasons including, but not limited to:

(1) Indigent care and bad debt loads;

(2) Medical education costs;

(3) Physician practice patterns;

(4) Capital requirements;

(5) Hospital location;

(6) Local labor market conditions; and

(7) Other operating requirements.

(G) Under no circumstances shall the name or social security number of a patient, dentist or physician be submitted under this rule.

Appendix A

Hospital Identification

Annual Hospital Data Disclosure Most Frequently Treated DRGs

Report Period: January 1, 20_____ - December 21, 20_____

This disclosure of data for inpatient discharges is required to be completed by all Ohio hospitals in accordance with section 3727.34 of the Ohio Revised Code, and rule 3701-14-01 of the Administrative Code.

1. Name of Hospital

2. ODH Number

3. Address

4. Telephone Number

5. City

6. County

7. ZIP

8. Name of Person Completing this Form

9. Telephone Number

10. E-mail Address of Person Completing Form

11. Type of Data:

.. Inpatient

.. Outpatient

Affidavit

Certification by the Hospital's Chief Executive Officer

I hereby certify that the information disclosed in accordance with section 3727.34 of the Ohio Revised Code and rule 3701-14-01 of the Administrative Code is true to the best of my knowledge.

Sworn to me and subscribed to in my presence, this _______________ day of _________________________________, 20______.

APPENDIX B

Description of Inpatient Data File Requirements

ELECTRONIC VERSION

This electronic file includes all of the numerical data required for reporting. It is in ASCII format, with one record per DRG reported, in a fixed length 215 character record. A carriage return is imbedded at the end of each record.

The file will be labeled with the Hospital's ODH registration number in the first four characters of the MS-DOS filename followed by a period, followed by "DAT". Example: 1100.DAT

FIELD IDENTIFICATION CHARACTER POSITIONS DECIMAL PLACES FIELD TYPE JUSTIFICATION SPECIAL INSTRUCTIONS

Hospital Numbers 1-4 A Left ODH Hospital ID number

DRG Number 5-7 A Left DRGs are reported in rank order from 1-60 with the DRG having the most number of patient admissions ranked first. If there are DRGs with an equal number of discharges, they are reported with the DRG having the highest average charge reported first. If DRG 468, 469 or 470 appears on the list of most frequently treated DRGs, the DRG or DRGs shall be removed from the list and next most frequently treated DRG or DRGs shall be added. DRGs for which the hospital treated fewer than 10 patients in the calendar year are not required to be reported.

N. of Discharges 11-15 N Right

Mean Charge 16-21 N Right

Median Charge 22-27 N Right

Lowest Charge 28-33 N Right

Highest Charge 34-40 N Right

Mean Los 41-46 2 N Right Decimal points are imbedded.

Median Los 47-52 1 N Right Decimal points are imbedded.

Lowest Los 53-55 N Right

Highest Los 56-59 N Right

N. of Emergency Admissions 60-64 N Right

N. of Hospital Transfers 65-69 N Right

Other Admissions 70-74 N Right

Comment Indicator 75 A Place an asterisk "*" in this field if comments will be included in the comment file for this DRG.

Severity of Illness Classification Levels Patients who are either charge or day outliers should not be included in severity data reported below. If the number of patients in any refined group number (RGN) is less than 3, information on charges and length of stay is not required for the RGN. There may be up to 7 RGN's for each DRG.

First Refined Group Numbers

RGN 76-79 A Right Refined Group Number

N. of Discharges 80-83 N Right

Mean Charges 84-89 N Right

Mean Los 90-95 2 N Right Decimal places are imbedded.

Second Refined Group Number

RGN 96-99 A Right Refined Group Number

N. of Discharges 100-103 N Right

Mean Charges 104-109 N Right

Mean Los 110-115 2 N Right Decimal places are imbedded.

Third Refined Group Numbers

RGN 116-119 A Right Refined Group Number

N. of Discharges 120-123 N Right

Mean Charges 124-129 N Right

Mean Los 130-135 2 N Right Decimal places are imbedded.

Fourth Refined Group Number

RGN 136-139 A Right Refined Group Number

N. of Discharges 140-143 N Right

Mean Charges 144-149 N Right

Mean Los 150-155 2 N Right Decimal places are imbedded.

Fifth Refined Group Number

RGN 156-159 A Right Refined Group Number

N. of Discharges 160-163 N Right

Mean Charges 164-169 N Right

Mean Los 170-175 2 N Right Decimal places are imbedded.

Sixth Refined Group Number

RGN 176-179 A Right Refined Group Number

N. of Discharges 180-183 N Right

Mean Charges 184-189 N Right

Mean Los 190-195 2 N Right Decimal places are imbedded.

Seventh Refined Group Number

RGN 196-199 A Right Refined Group Number

N. of Discharges 200-203 N Right

Mean Charges 204-209 N Right

Mean Los 210-215 2 N Right Decimal places are imbedded.

Appendix C

Annual Hospital Disclosure Inpatient Discharges Most Frequently Treated DRGs

Report Period: January 1, 20_____ - December 31, 20_____

Hospital Name

ODH Number

DRG Specific Utilization

Rank Order DRG Number DRG Name

Total Number of Discharges

Range

Mean Median Low High

Charges

Length of Stay

Admissions From

Emergency Hospital Transfer Other Admission Comment1

Refinement Group Number Number of Discharges Mean Charges Mean Length of Stay

1

2

3

4

5

6

7

1 Hospital may attach any commentary concerning reasons for major deviations in the range of data for any DRG.

Appendix D

Outpatient Data File Requirements

The file must be in ASCII format. The file includes one record per procedure reported in a fixed length 32 character record. A carriage return is imbedded at the end of each record.

The file must be labeled with the hospital's ODH registration number in the first four, followed a period, and followed by "out". Example: 1100.out

Field Identification Character Position Field Type Justification Special Instructions

ODH Hospital Registration Number 1-4 A Left

Procedure Number 5-9 A Left

Rank Order 10-11 A Left Procedures are reported in rank order from 1-60 with the procedure having the most number of visits ranked first. If there are procedures with equal number of cases, they are reported with the procedure having the highest mean charge reported first. Procedures for which the hospital treated less than 10 patients in the calendar year are not required to be reported.

Number of Patients 12-17 N Right

Mean Charge 18-24 N Right No decimal. Round to the nearest whole number

Median Charge 25-31 N Right No decimal. Round to the nearest whole number

Comment Indicator 32 A Left Place an Asterisk "*" in this field if comments will be included in the comment file.

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33 , 3727.36 , 3727.40 , 3727.41
Prior Effective Dates: 12/28/1987, 9/5/89, 1/27/07

3701-14-02 Definitions.

As used in rules 3701-14-02 to 3701-14-04 of the Administrative Code:

(A) "ACEI" or "angiotensin-converting enzyme inhibitor" means a medicine used for controlling blood pressure, treating heart failure, preventing strokes, and preventing kidney damage in people with hypertension or diabetes and improving survival after heart attacks.

(B) "AHRQ" means the agency for healthcare research and quality, a public health service agency in the United States department of health and human services.

(C) "AMI" or "acute myocardial infarction" means a heart attack that occurs when the blood supply to part of the heart is interrupted.

(D) "ARB" or "angiotensin receptor blocker" means a drug that helps relax blood vessels and is used for controlling high blood pressure, treating heart failure, and preventing kidney failure in people with diabetes or high blood pressure.

(E) "Bacteremia" means bacteria present in the blood stream, as confirmed by culture.

(F) "C. diff" or "clostridium difficile" means a bacterium that produces a toxin that causes an intestinal condition called colitis, sometimes with severe complications.

(G) "CABG" or "coronary artery bypass graft" means a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease.

(H) "CDC" means the centers for disease control and prevention within the United States department of health and human services.

(I) "Children's hospital" has the same meaning as in section 3702.51 of the Revised Code.

(J) "CMS" means the centers for medicare and medicaid services within the United States department of health and human services.

(K) "CWISH" means the council of women and infants' specialty hospitals which is a national membership organization of non-profit hospitals providing services to women and infants.

(L) "Department" means the department of health of the state of Ohio.

(M) "Director" means the director of the department of health of the state of Ohio or his or her duly authorized representative.

(N) "DSC" means the joint commission's disease specific care measure.

(O) "First calendar quarter" means the time period that includes the months of January, February, and March.

(P) "First quarter" means the first, second and third months of any twelve month period.

(Q) "Fourth calendar quarter" means the time period that includes the months of October, November, and December.

(R) "Fourth quarter" means the tenth, eleventh, and twelfth month of any twelve month period.

(S) "HCAHPS" or "hospital consumer assessment of healthcare providers and systems" means the survey developed by CMS to collect information on hospital patients' perspectives of the care they received while in the hospital.

(T) "HF" or "heart failure" means a cardiac condition that occurs when a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs.

(U) "Hospital" means an institution as defined in section 3727.01 of the Revised Code.

(V) "ICU" means intensive care unit.

(W) "IQI" or "inpatient quality indicator" means a measure developed by AHRQ to reflect quality of care in hospitals.

(X) "LVSD" or "left ventricular systolic dysfunction" means a common cause of heart failure due to a malfunctioning left ventricle of the heart.

(Y) "MRSA" or "methicillin resistant staphylococcus aureus" means a type of bacterium that can cause infections in humans that can not be successfully treated with semisynthetic penicillins.

(Z) "MSSA" or "methicillin susceptible staphylococcus aureus" means a type of bacterium that can cause infections in humans that can be successfully treated with semisynthetic penicillins.

(AA) "NPIC" means the national perinatal information center, a non-profit organization with a charter membership of major perinatal centers across the United States.

(BB) "NQF" means the national quality forum, a not-for-profit membership organization that endorses national consensus standards for measuring and public reporting on performance of health care providers.

(CC) "PCTA" or "percutaneous transluminal coronary angioplasty" means a medical procedure used to restore blood flow through a narrowed or blocked artery in the heart.

(DD) "PN" or "pneumonia" means a serious infection or inflammatory illness of the lungs which hinders oxygen reaching the lungs.

(EE) "PSI" or "patient safety indicator" means a measure developed by AHRQ to reflect potential inpatient complications and other patient safety concerns following surgeries, other procedures, and childbirth.

(FF) "Quarter" means a time period of three consecutive months.

(GG) "SCIP" or "surgical care improvement project" means a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications.

(HH) "Second calendar quarter" means the time period that includes the months of April, May, and June.

(II) "Second quarter" means the fourth, fifth, and sixth months of any twelve month period.

(JJ) "The Joint Commission" means the independent, not-for-profit organization formerly known as the joint commission on accreditation of healthcare organizations or the joint commission on accreditation of hospitals that accredits and certifies health care organizations and programs in the United States.

(KK) "Third calendar quarter" means the time period that includes the months of July, August, and September.

(LL) "Third quarter" means the seventh, eighth, and ninth months of any twelve month period.

(MM) "Twelve month reporting period" means a length of time comprised of twelve consecutive months.

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33
Prior Effective Dates: 6/28/2009

3701-14-03 Hospital performance measures reporting requirements.

(A) Except as otherwise provided in this rule, commencing with the first reporting deadline that occurs at least ninety days after the effective date of this rule, each hospital shall submit information to the director, in accordance with the provisions of rules 3701-14-02 to 3701-14-04 of the Administrative Code, showing the hospital's performance in meeting each of the measures specified in appendix A to rule 3701-14-04 of the Administrative Code.

(1) Not later than the first day of each April, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the twelve month reporting period ending on June thirtieth of the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of this reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth quarters of this reporting period. The third and fourth quarters of this reporting period are the first and second calendar quarters of the previous calendar year.

(2) Not later than the first day of each October, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures over the previous calendar year. Hospitals that have already submitted the performance measures for the first two quarters of the reporting period shall only submit information reflecting the hospital's performance in meeting the measures for the third and fourth calendar quarters of the previous calendar year.

(3) If the first reporting deadline that occurs at least ninety days after the effective date of this rule is October 1, 2009, each hospital shall submit information reflecting, by quarter, the hospital's performance in meeting the measures specified in rule 3701-14-04 of the Administrative Code for all of calendar year 2008.

(4) Children's hospitals are exempted from reporting a performance, quality or service measure for patients eighteen years of age or older.

(5) Hospitals that are not currently participating in the hospital consumer assessment of healthcare providers and systems shall commence reporting the HCAHPS measures beginning October 2011.

(6) Hospitals that are not stroke centers certified by the joint commission shall commence reporting the stroke measures beginning October 2012.

(B) In addition to the measures required to be reported in paragraph (A) of this rule:

(1) Beginning October 2010, each hospital shall report annually each October, the health care provider influenza vaccination information in appendix B to rule 3701-14-04 of the Administrative Code for the flu season beginning on September first of the previous calendar year and ending on March thirty-first of the reporting year; and

(2) Beginning October 2011, each hospital shall submit, in accordance with paragraph (A) of this rule, information reflecting the hospital's performance in meeting the perinatal and pediatric measures specified in appendix E to rule 3701-14-04 of the Administrative Code.

(C) The hand-washing program and infection control staff information shall be reported and updated once each reporting time period in April and October reflecting the information as of the end of the fourth quarter of the reporting period.

(D) The AMI thirty-day mortality measure shall be reported once annually each October reflecting the twelve month reporting period ending on June thirtieth of the previous calendar year.

(E) The following perinatal measures shall be calculated by the department from the birth records submitted by each hospital pursuant to section 3705.02 of the Revised Code:

(1) Infants under fifteen hundred grams not delivered at the appropriate level of care;

(2) Appropriate use of antenatal steroids; and

(3) Caesarean rate for low-risk first birth women.

(F) In submitting the information, each hospital shall do all of the following:

(1) Submit information for each measure electronically, in a manner prescribed by the director, through the department's website created for this purpose:

(a) If a hospital does not provide the service that is the subject of a performance, quality, or service measure, the hospital shall not enter any data for that measure.

(b) If a hospital commences operation or starts serving a new population in the middle of a calendar quarter, the hospital shall not enter any data for the partial quarter, but shall submit the performance measure information starting with the first full quarter of hospital operation or serving the new population.

(2) Submit the following identifying information:

(a) The hospital's name, address, hospital registration number issued pursuant to section 3701.07 of the Revised Code, medicare provider number, if applicable, and the hospital's main telephone number; and

(b) The name of the person submitting the information and a telephone number and e-mail address for that person.

(3) Submit the information for the hospital's services regardless of who pays the charges incurred for the services;

(4) Submit the numerator and denominator for each performance measure that is calculated as a per cent or rate; and

(5) Unless otherwise provided in rules 3701-14-03 and 3701-14-04 of the Administrative Code:

(a) Use the specifications for the measure that the entity that developed or endorsed the measure recommends be used for each quarter in the reporting period for which information is being submitted;

(b) If the specifications permit use of a sampling methodology, indicate if sampling is used to calculate the measure; and

(c) Adjust for risk, as needed, the information for a particular measure in accordance with the risk adjustment methodology that the entity that developed or endorsed the measure recommends be used for each quarter of the reporting period for which information is being submitted.

(G) Under no circumstances shall the name or social security number of a patient, physician, or dentist, or any other health care practitioner, be included in the information submitted under this rule.

(H) A hospital may include comments regarding the measures when submitting the information under rules 3701-14-02 to 3701-14-04 of the Administrative Code. The hospital's commentary shall be included in the display of the hospital's information on the department's internet website.

(I) The director may waive the reporting of a measure if the director determines that the entity that created or endorsed the measure has failed to timely make available updates to the measure, has materially altered the measure in such a way to make reporting or calculation of the measure unreasonably difficult, or has discontinued the measure.

(J) A hospital may verify the accuracy of, and make corrections to, the information submitted to the director or calculated by the department pursuant to rules 3701-14-02 to 3701-14-04 of the Administrative Code anytime prior to the data being made available to the public under paragraph (M) of this rule.

(K) A hospital shall submit amended data for the surgical site infection measures required to be reported if a procedure was performed in a period that has already been reported and an infection related to that procedure is detected subsequent to the initial submission of information:

(1) Within thirty days after the operative procedure if no implant is left in place; or

(2) Within three hundred sixty-five days after the operative procedure if an implant is left in place.

(L) The director may audit any information submitted to the director under section 3727.22 of the Revised Code and rules 3701-14-02 to 3701-14-04 of the Administrative Code, including information adjusted for risk. The director may accept the audit reports from the CMS and the joint commission that are pertinent to their measures, if the director determines the audit reports are representative of the reporting period in question.

(M) Not later than ninety days after a hospital submits information to the director under this rule, the director shall make the submitted information available for sale to any interested person or government entity and available on the department's internet website. The director shall:

(1) Exclude from sale and from the website, and not otherwise make available to the public, information that compromises patient privacy; and

(2) Exclude from the website, a hospital's information for a particular measure if the hospital's caseload is determined by the director to be insufficient to make the information a reliable indicator of the hospital's quality. The director shall consider the specifications manual issued by CMS and the joint commission when making this determination.

(N) If a hospital fails to timely submit the information required by rules 3701-14-02 to 3701-14-04 of the Administrative Code, the director may apply to the court of common pleas of the county in which a hospital is located for a temporary or permanent injunction restraining the hospital from failure to comply with these rules.

Replaces: 3701-14-02

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33 , 3727.331 , 3727.35 , 3727.39 , 3727.40 , 3727.41
Prior Effective Dates: 1/27/2007, 6/9/09

3701-14-04 Performance measures to be reported.

In accordance with rule 3701-14-03 of the Administrative Code, each hospital that is not a children's hospital shall report to the director all of the following measures, and each children's hospital shall report only the infection control measures and the pediatric measures listed in paragraphs (F) and (G) of this rule.

(A) The CMS and the joint commission's measures for acute myocardial infarction, heart failure, pneumonia, the surgical improvement project, and the hospital consumer assessment of healthcare providers and systems listed in appendix A to this rule.

(1) In calculating the appropriateness of care measure for acute myocardial infarction, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, and AMI-8a interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure, but not counted in the numerator of the AMI appropriateness of care measure.

(b) If an eligible patient receives all indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure and once in the numerator of the AMI appropriateness of care measure.

(2) In calculating the appropriateness of care measure for heart failure, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for HF-1, HF-2, HF-3 and HF-4 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure, but not counted in the numerator of the HF appropriateness of care measure.

(b) If an eligible patient receives all indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure and once in the numerator of the HF appropriateness of care measure.

(3) In calculating the appropriateness of care measure for pneumonia, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for PN-2, PN-3, PN-4, PN-5c, PN-6 and PN-7 who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure, but not counted in the numerator of the PN appropriateness of care measure.

(b) If an eligible patient receives all indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure and once in the numerator of the PN appropriateness of care measure.

(4) In calculating the appropriateness of care measure for the surgical care improvement project infection measures, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for SCIP-Inf-1, SCIP-Inf-2, and SCIP-Inf-3 interventions who received all indicated care they were eligible to receive.

(a) If an eligible patient did not receive all of the indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure, but not counted in the numerator of the SCIP appropriateness of care measure.

(b) If an eligible patient receives all indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure and once in the numerator of the SCIP appropriateness of care measure.

(B) The joint commission's stroke measures listed in appendix A to this rule.

(C) The AHRQ's heart and patient safety measures listed in appendix A to this rule.

(D) The centers for disease control and prevention's surgical site infection event measures listed in appendix A to this rule for the following procedures:

(1) CABG with chest incision only;

(2) Cesarean section; and

(3) Knee prosthesis, initial surgery only.

(E) The centers for disease control and prevention's measures for hospital acquired Clostridium difficile and hospital-acquired methicillin resistant and methicillin susceptible staphylococcus aureus bacteremia listed in appendix A to this rule for patients eighteen years of age or older, using the following reporting options, definitions, and specifications of the CDC's national health care safety network:

(1) The laboratory-identified even option;

(2) The facility-wide reporting option with only one denominator for the entire facility; and

(3) The healthcare facility-onset incident definition to calculate the measure.

(F) The infection control information pertaining to influenza vaccination, using the specifications in appendix B to this rule and the information pertaining to the hospital's hand-washing program and infection control staffing specified in appendix C to this rule.

(G) The following pediatric measures:

(1) The joint commission and NQF endorsed children's asthma care measures for systemic corticosteroids for inpatient asthma and relievers for inpatient asthma (ages two to seventeen) overall rate listed in appendix A to this rule; and

(2) Using the specifications prescribed in appendix D to this rule, the following measures listed in appendix E to this rule for patients less than eighteen years of age:

(a) Prophylactic antibiotic received within one hour prior to surgical incision;

(b) Surgical site infection rates for cardiothoracic, neurosurgical and orthopedic procedures; and

(c) Catheter-associated bloodstream infection rate for ICU patients.

(H) Except as otherwise indicated in paragraph (E) of rule 3701-14-03 of the Administrative Code, the perinatal measures listed in appendix E to this rule:

Appendix A

Centers for Medicare and Medicaid Services (CMS)/The Joint Commission

*Denotes NQF Endorsed

Acute Myocardial Infarction*

All-or-none measure (AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-8a)

AMI-1: Aspirin at Arrival

AMI-2: Aspirin at Discharge

AMI-3: ACEI or ARB for LVSD

AMI-4: Smoking Cessation Counseling

AMI-5: Beta Blocker at Discharge

AMI-8a: Primary PCI received within 90 minutes of hospital arrival

Mort-30-AMI: AMI 30-Day Mortality

Heart Failure*

All-or-none measure (HF-1, HF-2, HF-3, HF-4)

HF-1: Discharge Instructions

HF-2: Evaluation of left ventricular systolic (LVS) Function

HF-3: ACEI or ARB for LVSD

HF-4: Smoking Cessation Counseling

Pneumonia*

All-or-none measure ( PN-2, PN-3b, PN-4, PN-5c, PN-6, PN-7)

PN-2: Pneumococcal Vaccination

PN-3b: Blood Culture Performed in Emergency Department Prior to Initial Antibiotic Received in Hospital

PN-4: Smoking Cessation Counseling

PN5c: Initial Antibiotic received within 6 hours of hospital arrival

PN-6: Initial Antibiotic Selection for Community-Acquired Pneumonia in Immunocompetent Patients

PN-7: Influenza Vaccination

Surgical Care Improvement Project (SCIP)*

Appropriateness of care measure (SCIP-Inf 1, 2, 3)

SCIP-Inf 1a: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate

SCIP-Inf 1b: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG

SCIP-Inf 1c: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery

SCIP-Inf 1d: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty

SCIP-Inf 1e: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty

SCIP-Inf 1f: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery

SCIP-Inf 1g: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy

SCIP-Inf 1h: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery

SCIP-Inf-2a: Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate

SCIP-Inf-2b: Prophylactic Antibiotic Selection for Surgical Patients - CABG

SCIP-Inf-2c: Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery

SCIP-Inf-2d: Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty

SCIP-Inf-2e: Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty

SCIP-Inf-2f: Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery

SCIP-Inf-2g: Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy

SCIP-Inf-2h: Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued within 24 Hours after Surgery End Time - Overall Rate

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - CABG

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hysterectomy

SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery

SCIP-Card-2: Surgery Patients on Beta Blocker Therapy Prior to Admission who Received a Beta Blocker during

SCIP-VTE-1: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered

SCIP-VTE-2: Surgery Patients who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours after Surgery

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Communication with Nurses

Communication with Doctors

Responsiveness of Hospital Staff

Pain Management

Communication about Medicines

Cleanliness of Hospital Environment

Quietness of Hospital Environment

Discharge Information

Overall Rating of this Hospital

Willingness to Recommend This Hospital

Joint Commission

Stroke Measures

DSC/Stroke-01: Deep Vein Thrombosis (DVT) Prophylaxis

DSC/Stroke-02: Discharged on Antithrombotic Therapy

DSC/Stroke-03: Patients with Atrial Fibrillation Receiving Anticoagulation Therapy

DSC/Stroke-04: Thrombolytic Therapy Administered

DSC/Stroke-05: Antithrombotic Therapy by End of Hospital Day Two

DSC/Stroke-06: Discharged on Cholesterol Reducing Medication

DSC/Stroke-07: Dysphagia Screening

DSC/Stroke-08: Stroke Education

DSC/Stroke-09: Smoking Cessation /Advice/Counseling

DSC/Stroke-10: Assessed for Rehabilitation

Agency for Healthcare Research and Quality (AHRQ)

Other Heart Measures

IQI-6: Percutaneous Coronary Intervention (Angioplasty) (PCTA) volume

IQI-30: Percutaneous Coronary Intervention (Angioplasty) (PCTA) mortality rate

IQI-5: Coronary Artery Bypass Graft (CABG) volume

IQI-12: Coronary Artery Bypass Graft (CABG) mortality rate

Patient Safety Measures

PSI-1: Complications of Anesthesia

PSI-3: Decubitus Ulcer

PSI-5: Foreign Body Left During Procedure

Infection Measures

*Denotes NQF Endorsed

Centers for Disease Control and Prevention- National Healthcare Safety Network (NHSN)

Surgical Site Infection Event - Coronary artery bypass graft with chest incision only *

Surgical Site Infection Event - Cesarean Section*

Surgical Site Infection Event - Knee Prosthesis, initial surgery only*

Hospital-Acquired Clostridium difficile (C. Diff.)

Hospital-Acquired Methicillin Resistant and Methicillin Susceptible Staphylococcus aureus Bacteremia (MRSA/MSSA Bacteremia) (SAB)

Infection Control Information

Hand-washing Program

Infection Control Staffing

Perinatal Measures

*Denotes NQF Endorsed

California Maternal Quality Care Collaborative

Cesarean Rate for Low-Risk First Birth Women (NTSV CS Rate)*

Infants Under 1500g Not Delivered at Appropriate Level of Care*

Providence St. Vincent's Hospital/CWISH

Appropriate use of Antenatal Steroids*

Pediatric Measures

*Denotes NQF Endorsed

The Joint Commission - Children's Asthma Care

CAC-1a: Systemic Corticosteroids for Inpatient Asthma (age 2-17) overall rate*

CAC-2a: Relievers for Inpatient Asthma (age 2-17) overall rate*

Appendix B

Health Care Provider Influenza Vaccination Measure

Measure Name -- Health Care Provider Influenza Vaccination

Data Source -- Hospital Employee Health Records

Numerator -- Number of paid employees receiving either nasal spray or shot of Influenza vaccine from September 1 to March 31

Denominator -- Total number of paid hospital employees that were employed as of March 31

Exclusions -- None

Note:

-- Count all employees who received a vaccination regardless of where they received the vaccination (i.e. physician's office or clinic)

-- Count paid employees as of March 31st each year

-- Count only employees who work in an inpatient facility

APPENDIX C

Hand-washing Program and Infection Control Staffing

Hand Washing:

1. Does your hospital have a program to improve hand hygiene practices?

Yes

No

Under development

2. Does your hospital teach principles of hand hygiene and proper use of gloves to all clinical staff upon hire?

Yes

No

3. Does your hospital monitor and provide feedback to clinical staff regarding their hand hygiene practices?

Yes, both

Partial, monitor only

No

4. In your hospital's clinical settings, are alcohol-based hand rubs available for use at the point of care?

Yes

No

5. In your hospital's clinical settings, are gloves available for use at the point of care?

Yes

No

6. Does your hospital prohibit the wearing of artificial nails by direct-care providers?

Yes

No

Staffing:

1. Does your hospital employ a qualified Infection Control Professional (ICP)?

Yes

No

2. Does your hospital employ an Infection Control Professional (ICP)/Infection Preventiionist who is board certified in infection control (CIC)? (To qualify for the certification examination, one must have a baccalaureate degree OR current license as medical technologist, clinical laboratory scientist, physician or registered nurse AND a minimum of two years experience in infection control practice within the most current five year period and with a minimum of 800 hours worked prior to the date of the examination.)

Yes

No

3. Does your hospital have a board-certified Infectious Disease Physician either on staff or available for consult?

Yes

No

APPENDIX D

PEDIATRIC MEASURE SPECIFICATIONS

Measure: Percentage of Patient Trips to the Operating Room with Prophylactic Antibiotics Initiated 0-60 Minutes Prior to Incision; 0-120 minutes for those antimicrobials that require a longer infusion time.

The National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol list of designated surgical procedures governing the reporting period for which information is being submitted will serve as the official reference guide for eligible surgical procedures.

I. Population Definition (Note: All designated surgical procedures require prophylactic antibiotics.)

Inclusion Criteria:

Patients < 18 years of age, as of the date the designated surgical procedures are performed.

Exclusion Criteria:

Patients > 18 years of age, as of the date the designated surgical procedures are performed.

Patients with physician, advanced practice nurse, or physician assistant documentation of any type of active infection at the time of the designated surgical procedures.

II. Calculation

Numerator: Number of patient trips to the operating room for designated surgical procedures where required prophylactic antibiotics were initiated 0-60 minutes prior to incision (0-120 minutes for those antimicrobials that require a longer infusion time).

Denominator: Number of patient trips to the operating room for designated surgical procedures performed during the applicable reporting period in patients < 18 years of age, as of the date the procedures are performed.

Note: A patient trip to the operating room is counted only once, regardless of the number of procedures performed.

(Numerator/Denominator) x 100 (Note: reported as a percentage)

III. Data Collection/Reporting

Instances where required prophylactic antibiotics were not administered are counted the same as not initiated 0-60 minutes prior to incision (0-120 minutes for those antimicrobials that require a longer infusion time).

IV. Notes

Appropriate timing of antibiotic re-dosing during surgical procedures is not addressed.

Appropriate antibiotic selection is not addressed.

Adjusting data for differences in case mix, volumes, or patient severity across reporting hospitals is not required for this measure.

V. Eligible Surgical Procedures

The neurosurgical, orthopedic, and cardiothoracic procedures and corresponding CPT and ICD-9-CM procedure codes, based on the following Centers for Disease Control/National Healthcare Safety Network reporting categories: VSHN, FUSN, and CARD.

Measure: Surgical Site Infections (SSI) per 100 Patient Trips to the Operating Room

The National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol and list of eligible surgical procedures governing the reporting period for which information is being submitted will serve as the official reference guide for defining/reporting surgical site infections of the pediatric population. However, hospitals are not required to use the NHSN forms or prepare monthly surveillance plans for purposes of reporting this measure.

I. Population Definition

Inclusion Criteria:

Patients < 18 years of age, as of the date the designated surgical procedures are performed.

Exclusion Criteria:

Patients > 18 years of age, as of the date the designated surgical procedures are performed.

II. Calculation

Numerator: Number of SSIs related to designated surgical procedures.

Denominator: Number of patient trips to the operating room for designated surgical procedures during the applicable reporting period in patients < 18 years of age, as of the date the procedures are performed.

Note: A patient trip to the operating room is counted only once, regardless of the number of procedures performed.

(Numerator/Denominator) x 100 (Note: reported as SSIs per 100 patient trips to the operating room.)

III. Data Collection/Reporting

CDC-defined surveillance periods for identifying SSIs:

-- 30 days for non-implanted devices.

-- 365 days for implanted devices.

Minimum required scope of surveillance to identify SSIs includes hospital-based encounters (e.g. inpatient, ED/urgent care, hospital-based outpatient clinics).

SSI rate is reported separately for each of the following surgical procedure categories: neurosurgical, orthopedic, and cardiothoracic.

SSIs are assigned to the month when the attributable surgical procedures were performed.

Due to challenges communicating information across hospitals, should the attributable procedure be performed at a hospital other than the hospital where the

SSI was identified, the following guidelines apply:

-- Hospital performing attributable procedure: add patient trip to the operating room to the denominator, even if unable to add the related SSI to the numerator (due to lack of awareness that the SSI has occurred); add SSI to the numerator if aware that the SSI has been identified by another hospital.

-- Hospital identifying the SSI: exclude SSI from the numerator since the patient trip to the operating room where the attributable procedure was performed is within the denominator of a different hospital. (Note: hospital identifying the SSI should contact the infection control department of the hospital that performed the attributable procedure; cross-hospital communication of patient information should comply with legal, legislative, and regulatory requirements.)

IV. Notes

NHSN SSI risk-adjustment methodologies will not be utilized. NHSN algorithm based on operation duration, wound class, and ASA classification has not been validated for pediatric populations. As pediatric-specific SSI prevalence rates for the designated surgical procedures are not available from evidence-based literature, the alternative NHSN methodology based on "observed vs. expected" cannot be applied.

V. Eligible Surgical Procedures

The neurosurgical, orthopedic, and cardiothoracic procedures and corresponding CPT and ICD-9-CM procedure codes, based on the following Centers for Disease Control/National Healthcare Safety Network reporting categories: VSHN, FUSN, and CARD.

Measure: Laboratory-Confirmed Catheter-Associated Bloodstream Infections (CABSI) per 1,000 Catheter Days for ICU Patients

I. Population Definition

Inclusion criteria:

All patients < 18 years of age on date of admission or re-admission to ICU setting who have a central venous catheter.

Includes patients in applicable ICU settings with central venous catheters regardless of place of insertion (e.g., tunneled/implanted central lines inserted in OR, PICC lines inserted in interventional radiology).

Includes all ICU settings, except NICUs.

Includes immunocompromised patients.

Includes the following catheter types:

-- Tunneled/implanted central line (e.g., Hickman, Broviac, Mediport).

-- Percutaneous central line (e.g., central venous catheter, subclavianinserted central catheter).

-- Peripherally-inserted central catheter (PICC): must be threaded in or near heart or great vessel to qualify as "central line."

-- Umbilical venous catheter.

NHSN definition of central line: intravascular catheter that terminates at, or close to, the heart, or in one of the great vessels, which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

Patients with an existing central venous catheter where a CA-BSI develops within 48 hours after inter- or intra-hospital transfer from an ICU within the hospital reporting this measure to another clinical setting (e.g., inpatient unit, ICU). (Note: the hospital reporting this measure should capture catheter days for these patients in their denominator, and the CA-BSIs for these patients in their numerator.)

Exclusion Criteria:

Patients > 18 years of age on date of admission or re-admission to ICU setting.

Patients in the NICU. (Note: NICUs within children's hospitals are part of this exclusion criteria; decisions regarding NICU-related quality measures for public reporting were deferred to the ODH Perinatal Workgroup.)

Catheter days for patients while in the NICU and infections attributed to the NICU are excluded.

Intermediate care unit patients.

Patients with an existing central venous catheter where a CA-BSI develops within 48 hours after inter- or intra-hospital transfer to an ICU within the hospital reporting this measure.

II. Calculation

Numerator: Number of laboratory-confirmed CA-BSIs.

Clarifications:

Positive blood cultures drawn from multiple sites are counted as one infection if due to the same organism.

A laboratory-confirmed bloodstream infection (LCBI) must meet one of the following three criteria: (Note: LCBI criteria 1 and 2 may be used for patients of any age, including patients < 1 year of age.) (Source: "CDC/NHSN Surveillance Definition of Health-Care Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting," American Journal of Infection Control, 2008; 36: 309-332; National Association of Children's Hospitals and Related Institutions CA-BSI collaborative.)

Criterion 1:

Patient has a recognized pathogen cultured from one or more blood cultures

And

Organism cultured from blood is not related to infection at another site. (See Notes 1 and 2 in addendum.)

Criterion 2:

Patient has at least one of the following signs/symptoms: fever (>38°C), chills, or hypotension

And

Signs/symptoms and positive laboratory results are not related to an infection at another site

And

Common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. (See Notes 3 and 4 in addendum.)

Criterion 3:

Patient < 1 yr of age has at least one of the following signs or symptoms: fever (>38°C, rectal), hypothermia (<37°C, rectal), apnea, or bradycardia.

Note: for patients < 1 year of age, the following temperature equivalents for fever and hypothermia may be used:

-- Fever: 38°C rectal/tympanic/temporal artery=37°C oral=36°C axillary.

-- Hypothermia: 37°C rectal/tympanic/temporal artery=36°C oral=35°C axillary.

And

Signs/symptoms and positive laboratory results are not related to an infection at another site

And

Common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. (See Notes 3 and 4 in addendum.)

Denominator: Number of catheter days during applicable reporting period in patients < 18 years of age on date of admission or re-admission to ICU setting.

Clarifications:

Definition of "catheter days" sum of patients with 1 or more central lines (excluding arterial lines), measured at the same time each day.

Patients with multiple central lines, and central lines with multiple lumens/ports per line, are counted as 1 catheter day.

Only count line days that occurred within applicable ICU settings.

For patients transferred between ICUs within the same hospital, line days are combined across applicable ICU settings for the reporting period.

-- E.g. During the reporting period, a patient is admitted to the NICU, is later transferred to an applicable ICU setting, and then is transferred back to the NICU. As the NICU is not an applicable ICU setting, catheter days associated with that setting are not counted in the denominator.

(Numerator/Denominator) x 1,000 (Note: reported as CA-BSIs per 1,000 catheter days.)

III. Data Collection/Reporting

Data is reported to the ODH on a quarterly basis.

Due to challenges communicating information across hospitals, should corresponding catheter days be recorded by a hospital other than the hospital where the CA-BSI was identified, the following guidelines apply:

-- Hospital reporting this measure: add catheter days to denominator, even if unable to add related CA-BSI to numerator (due to lack of awareness/knowledge that the CA-BSI has occurred); add the CA-BSI to numerator if aware that the CA-BSI was identified by another hospital.

-- Hospital identifying the CA-BSI: exclude the CA-BSI from numerator since corresponding catheter days are within the denominator of a different hospital. (Note: hospital identifying the CA-BSI should contact the infection control department of hospital where patient previously received care; cross-hospital communication of patient information should comply with legal, legislative and regulatory requirements.)

IV. Notes

Data is not adjusted for differences in case mix, volumes, or patient severity across reporting hospitals

Measure does not distinguish between infections due to central venous catheter insertion vs. maintenance practices.

Specimen collection considerations (Source: "CDC/NHSN Surveillance Definition of Health-Care Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting," American Journal of Infection Control, 2008; 36: 309-332): ideally, blood culture specimens should be obtained from two to four blood draws from separate venipuncture sites (e.g., right and left antecubital veins), not through a vascular catheter. These blood draws should be performed simultaneously or over a short period of time (i.e., within a few hours). If the hospital does not currently obtain specimens using this technique, BSIs can still be reported based on the aforementioned criteria and notes listed in the addendum, but the hospital should work with appropriate personnel to facilitate better specimen collection practices for blood cultures.

VI. Addendum

Notes from CDC/NHSN Surveillance Definition of Health-Care Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting, American Journal of Infection Control, 2008; 36: 309-332:

1. In criterion 1, the phrase "gone or more blood cultures" means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms (i.e., "positive" blood culture).

2. In criterion 1, the term "recognized pathogen" does not include organisms considered common skin contaminants (see criteria 2 and 3 for list of common skin contaminants). Examples of "recognized pathogens" include: S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., and Candida spp.

3. In criteria 2 and 3, the phrase "two or more blood cultures drawn on separate occasions" means: 1) that blood from at least two blood draws were collected within two days of each other (e.g., blood draws on Monday and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on separate occasions, but blood draws on Monday and Thursday would be too far apart to meet this criterion), and 2) that at least one bottle from each blood draw is reported by the laboratory as having grown the same common skin contaminant organism (i.e., "positive" blood culture). (See Note 4 for determining sameness of organisms.)

a. Example: an adult patient has blood drawn at 8 a.m. and again at 8:15 a.m. of the same day. Blood from each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood draw set is positive for coagulase-negative staphylococci, this part of the criterion is met.

b. Example: A neonate has a blood culture drawn on Tuesday and again on Saturday, and both grow the same common skin contaminant. Because time between blood cultures exceeds the two-day period for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met.

c. A blood culture may consist of a single bottle for a pediatric blood draw because of volume constraints. Therefore, to meet this part of the criterion, each bottle from two or more draws would have to be culturepositive for the same skin contaminant.

4. There are several issues to consider when determining sameness of organisms.

a. If the common skin contaminant is identified to the species level from one culture, and a companion culture is identified with only a descriptive name (i.e., to the genus level), then it is assumed that the organisms are the same. The speciated organism should be reported as the infecting pathogen (see table below).

Culture -- Companion Culture -- Report as ...

S. epidermidis -- Coagulase-negative staphylococci -- S. epidermidis

Bacillus spp. (not anthracis) -- B. cereus -- B. cereus

S. salivarius -- Strep viridans --

S. salivarius

b. If common skin contaminant organisms from the cultures are speciated but no antibiograms are done, or they are done for only one of the isolates, it is assumed that the organisms are the same.

c. If the common skin contaminants from the cultures have antibiograms that are different for 2 or more antimicrobial agents, it is assumed that the organisms are not the same (see table below).

d. For the purpose of NHSN antibiogram reporting, the category interpretation of intermediate (I) should not be used to distinguish whether two organisms are the same.

Organism Name -- Isolate A -- Isolate B -- Interpret as... S epidermidis -- All drugs S -- All drugs S -- Same

S. epidermidis -- OX R CEFAZ R -- OX S CEFAZ S -- Different

Corynebacterium spp. -- PENG R CIPRO S -- PENG S CIPRO R -- Different

Strep viridans -- All drugs S -- All drugs S except ERYTH R -- Same

Appendix E

Perinatal Measures

*Denotes NQF Endorsed

Christiana Care Health Services/NPIC

Incidence of Episiotomy*

HCA-St Marks Perinatal Center

Elective Delivery Prior to 39 Completed Weeks Gestation*

Pediatric Measures

Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision

Catheter-Associated Bloodstream Infection Rate for ICU Patients

Surgical Site Infection Rate for cardiothoracic, neurosurgical and orthopedic procedures

Replaces: 3701-14-02

Five Year Review (FYR) Dates: 09/17/2014 and 09/15/2019
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33 , 3727.41
Prior Effective Dates: 1/27/2007, 6/28/09