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

Effective: 06/28/2009
R.C. 119.032 review dates: 06/01/2014
Promulgated Under: 119.03
Statutory Authority: 3727.41
Rule Amplifies: 3727.33 , 3727.41
Prior Effective Dates: 1/27/2007