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(ami-1) aspirin at arrival

CORE MEASURES

JCAHO, CMS, The American Hospital Association, Leapfrog and other
industry groups interested in improving and recognizing quality in healthcare
organizations have adopted a set of population specific, evidence-based quality
measures. These are mainly process measures or interventions which have been
proven to result in better outcomes when followed.
Standardized definitions allow hospitals to be compared to one another with the
goal of improving performance across the industry.
Saint Francis is currently participating in and reporting these measures for
three populations :

1. Acute Myocardial Infarction (AMI)
2. Heart Failure (HF)
3. Pneumonia (PN)

Future populations include:
1. Surgical Site Infection Prevention (SIP)
2. ICU


NOTE: All populations are identified by their diagnostic and procedural codes
assigned after discharge.


Core Measure definitions:
(AMI-1) Aspirin at arrival

Description: Acute myocardial infarction (AMI) patients without aspirin contraindications
who received aspirin within 24 hours before or after hospital arrival.
Rationale: Early treatment with aspirin, whether alone or in conjunction with reperfusion,
markedly reduces mortality from AMI. Accordingly, aspirin now plays an important role in
the early management of all patients with suspected AMI and should be administered
promptly.
Excludes:
• Patients transferred from another acute care hospital or emergency room. • Patients transferred to another acute care hospital
(AMI-2) Aspirin prescribed at discharge

Description: Acute myocardial infarction (AMI) patients without aspirin contraindications
who are prescribed aspirin at hospital discharge.
Rationale: The long-term use of aspirin after AMI confers a significant reduction in
mortality, non-fatal re-infarction, and non-fatal stroke.
Excludes:
• Patients transferred to another acute care hospital, • Patients who expired, • Patients who left against medical advice and (AMI-3) ACEI for LVSD

Description: Acute myocardial infarction (AMI) patients with left ventricular systolic
dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACEI)
contraindications who are prescribed an ACEI at hospital discharge. For purposes of this
measure, LVSD is defined as chart documentation of a left ventricular ejection fraction
(LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent
with moderate or severe systolic dysfunction.
Rationale: ACEI reduces mortality in patients with LVSD after AMI. In addition, the
likelihood of a recurrent myocardial infarction may also be reduced. Clinical trials have
established that the use of ACEI initiated after recovery from an AMI improves long-term
survival, with greater treatment benefit in patients with anterior infarctions or LVSD.
Includes: Patients with chart documentation of a LVEF less than 40% or a narrative
description of LVF consistent with moderate or severe systolic dysfunction
Excludes:
• Patients less than 18 years of age • Patients transferred to another acute care hospital • Patients who left against medical advice • Patients discharged to hospice • Patients with chart documentation of participation in a clinical trial testing alternatives to ACEIs as first-line heart failure therapy • Patients with one or more of the following ACEI contraindications/reasons for not prescribing ACEI documented in the medical record: ƒ ACEI allergy; ƒ Moderate or severe aortic stenosis; ƒ Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing ACEI at discharge.
(AMI-4) Adult smoking cessation advice/counseling

Description: Acute myocardial infarction (AMI) patients with a history of smoking
cigarettes, who are given smoking cessation advice or counseling during hospital stay. For
the purposes of this measure, a smoker is defined as someone who has smoked cigarettes
anytime during the year prior to hospital arrival.
Rationale: Smoking cessation is essential in patients with AMI. Smoking triggers coronary
spasm, reduces the anti-ischemic effects of beta blockers, and doubles mortality after AMI.
Patients who receive even brief smoking-cessation advice from their physicians are more
likely to quit than those who receive no counseling at all. Hospitalization can be an ideal
opportunity for a patient to stop smoking, and smoking cessation may promote the patient’s
medical recovery.
Includes: AMI patients with a history of smoking cigarettes anytime during the year prior
to hospital arrival.
Excludes:
• Patients transferred to another acute care hospital • Patients who expired • Patients who left against medical advice
(AMI-5) Beta blocker prescribed at discharge

Description: Acute myocardial infarction (AMI) patients without beta blocker
contraindications who are prescribed a beta blocker at hospital discharge.
Rationale: The use of beta blockers in post-myocardial infarction is associated with a lower
risk of long-term morbidity and mortality. In spite of the documented benefits of these
agents, there is evidence of substantial under-use in appropriate patients nationwide.
Excludes:
• Patients less than 18 years of age • Patients transferred to another acute care hospital • Patients who left against medical advice • Patients discharged to hospice • Patients with one or more of the following beta blocker contraindications/reasons for not prescribing a beta blocker documented in the medical record: ƒ Beta blocker allergy; ƒ Bradycardia (heart rate less than 60 bpm) on day of discharge or day prior to ƒ Second or third degree heart block on ECG on arrival or during hospital stay and ƒ Systolic blood pressure less than 90 mm Hg on day of discharge or day prior to discharge while not on a beta blocker; or • Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing a beta blocker at discharge. (AMI-6) Beta blocker at arrival

Description: Acute myocardial infarction (AMI) patients without beta blocker
contraindications who received a beta blocker within 24 hours after hospital arrival.
Rationale: Beta blockers administered to patients with AMI during the initial hours of
presentation reduce morbidity and/or mortality. Immediate administration of beta blocker
therapy appears to reduce the magnitude of infarction and associated complications in
subjects not receiving concomitant thrombolytic therapy. Beta blockers also reduce the rate
of reinfarction in patients receiving thrombolytic therapy. Results from the National
Cooperative Cardiovascular Project demonstrate that beta blockers are substantially
underutilized nationwide.
Excludes:
• Patients transferred to another acute care hospital on day of arrival • Patients received in transfer from another acute care hospital on day of arrival, • Patients discharged on day of arrival • Patients who expired on day of arrival • Patients who left against medical advice on day of arrival • Patients with one or more of the following beta blocker contraindications/reasons for not prescribing beta blocker documented in the medical record: ƒ Beta blocker allergy; ƒ Bradycardia (heart rate less than 60 bpm) on arrival or within 24 hours after ƒ Heart failure on arrival or within 24 hours after arrival; ƒ Second or third degree heart block on ECG on arrival or within 24 hours after ƒ Shock on arrival or within 24 hours after arrival; ƒ Systolic blood pressure less than 90 mm Hg on arrival or within 24 hours after ƒ Other reasons documented by a physician, nurse practitioner, or physician assistant for not giving a beta blocker within 24 hours after hospital arrival. (AMI-7) Time to thrombolysis

Description: Mean time from arrival to administration of thrombolytic agent in patients
with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram
(ECG) performed closest to hospital arrival time.
Rationale: The timing of reperfusion is critical to the effective management of patients with
AMI. Patients presenting with AMI and ST segment elevation or LBBB are at relatively
high risk of death. This risk may be reduced by thrombolytic therapy, but only if it is
administered in a timely manner. Delays in the administration of thrombolytic agents may
reflect a wide range of factors including misdiagnosis at presentation, flaws in institutional
structures, or factors beyond the control of the caregiver.
Includes patients with:
• ST segment elevation or LBBB on the ECG performed closest to hospital arrival • Thrombolytic therapy within 6 hours after hospital arrival Excludes:
• Patients less than 18 years of age • Patients received in transfer from another acute care hospital including another (AMI-7a) Thrombolytic agent received within 30 minutes of hospital arrival.
Description: Acute myocardial infarction (AMI) patients receiving primary thrombolytic
therapy during the hospital stay with a time from hospital arrival to thrombolysis of 30
minutes or less.
Rationale: Time to thrombolytic therapy is a strong predictor of outcome in patients with an
acute myocardial infarction. Nearly 2 lives per 1000 patients are lost per hour of delay
(Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group, 1994). National guidelines
recommend that thrombolytic therapy be given within 30 minutes of hospital arrival in
patients with ST elevation myocardial infarction (Ryan, 1999). Despite these
recommendations, few older patients hospitalized with AMI receive timely thrombolytic
therapy (Jencks, 2000).
Includes patients with:
• ST segment elevation or LBBB on the ECG performed closest to hospital arrival • Thrombolytic therapy within 6 hours after hospital arrival Excludes:
• Patients received in transfer from another acute care hospital including another (AMI-8) Time to PCI

Description: Mean time from arrival to percutaneous coronary intervention(PCI) in patients
with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram
(ECG) performed closest to hospital arrival time.
Rationale: The timing of reperfusion is critical to the effective management of patients with
AMI. Patients presenting with AMI and ST segment elevation or LBBB are at relatively
high risk of death. This risk may be reduced by PCI, but only if it is performed in a timely
manner. Delays in the implementation of PCI may reflect a wide range of factors including
misdiagnosis at presentation, flaws in institutional structures, or factors beyond the control
of the caregiver.
Includes patients with:
• ST segment elevation or LBBB on the ECG performed closest to hospital arrival • PCI performed within 24 hours after hospital arrival Excluded Populations:
• Patients received in transfer from another acute care hospital including another • Patients administered thrombolytic agents
(AMI-8a) PCI received within 120 minutes of hospital arrival.
Description: Acute myocardial infarction (AMI) patients receiving primary percutaneous
coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI
of 120 minutes or less.
Rationale: The early use of primary angioplasty in patients with acute myocardial infarction
who present with ST-segment elevation or LBBB results in a significant reduction in
mortality and morbidity. The earlier primary coronary intervention is provided, the more
effective it is (Brodie, 1998). National guidelines recommend initiation of PCI within 120
minutes after hospital arrival inpatient with ST elevation myocardial infarction (Ryan,
1999). Despite these recommendations, few older patients hospitalized with AMI receive
primary angioplasty within a timely manner (Jencks, 2000).
Includes patients with:
• ST segment elevation or LBBB on the ECG performed closest to hospital arrival • PCI performed within 24 hours after hospital arrival Excluded Populations:
• Patients received in transfer from another acute care hospital including another • Patients administered thrombolytic agents
(AMI-9) Inpatient mortality

Description: Acute myocardial infarction (AMI) patients who expired during hospital stay.
Rationale: Mortality of patients with AMI represents a significant outcome potentially
related to quality of care. This rate-based indicator identifies an undesirable outcome of care.
High rates over time may warrant investigation into the quality of care provided.
Excludes:
• Patients transferred to another acute care hospital • Patients received in transfer from another acute care hospital • Patients discharged to hospice Note: The measure population does not include deaths that occurred in the emergency department.
(HF-1) Discharge instructions

Description: Heart failure patients discharged home with written instructions or educational
material given to patient or care giver at discharge or during the hospital stay addressing all
of the following: activity level, diet, discharge medications, follow-up appointment, weight
monitoring, and what to do if symptoms worsen.
Rationale: In the United States, it is estimated that 4.7 million persons have heart failure.
Mortality rates are high, and as our population ages, the incidence and mortality are
expected to increase. Educating patients with heart failure and their families is critical.
Patient non-compliance with physician’s instructions is often a cause of re-hospitalization. It
is thus important that health care professionals ensure that patients and their families
understand the prognosis of heart failure, the rationale for pharmacotherapy, dietary
restrictions, and activity recommendations, prescribed medication regimen, and the signs
and symptoms of worsening heart failure. Additionally, patients discharged from the
hospital after an exacerbation of heart failure should have follow-up to ensure clinical
stability.
Numerator Statement: Heart failure patients with documentation that they or their
caregivers were given written discharge instructions or other educational material addressing
all of the following:
1. activity level 2. diet 3. discharge medications 4. follow-up appointment 5. weight monitoring 6. what to do if symptoms worsen
Includes
patients with:
• A discharge to home, home care, or home IV therapy.
Excludes: Patients less than 18 years of age

(HF-2) LVF assessment

Description: Heart failure patients with documentation in the hospital record that left
ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned
for after discharge.
Rationale: In the United States, it is estimated that 4.7 million persons have heart failure.
Mortality rates are high, and as our population ages, the incidence and mortality are
expected to increase. Measurement of left-ventricular performance is a critical step in the
evaluation and management of almost all patients with suspected or clinically evident heart
failure. The combined use of history, physical examination, chest x-ray, and
electrocardiography cannot reliably distinguish between the major categories of heart
failure: left-ventricular systolic dysfunction, left-ventricular diastolic dysfunction, or a non-
cardiac etiology. If a measurement of ventricular performance is not obtained in patients
presenting with heart failure, appropriate treatment may be withheld. Specifically, patients
with left ventricular systolic dysfunction will not be identified and treated with agents
known to prolong life.
Excludes:
• Patients transferred to another acute care hospital • Patients who expired • Patients who left against medical advice • Patients discharged to hospice • Patients with reasons documented by a physician, nurse practitioner, or physician (HF-3) ACEI for LVSD

Description: Heart failure patients with left ventricular systolic dysfunction (LVSD) and
without angiotensin converting enzyme inhibitor (ACEI) contraindications who are
prescribed an ACEI at hospital discharge. For purposes of this measure, LVSD is defined as
chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a
narrative description of left ventricular function (LVF) consistent with moderate or severe
systolic dysfunction.
Rationale: In the United States, it is estimated that 4.7 million persons have heart failure.
Mortality rates are high, and as our population ages, the incidence and mortality are
expected to increase. Treatment with ACEI reduces morbidity and mortality in patients with
heart failure and LVSD.
Includes patients with:
• Chart documentation of a LVEF less than 40% or a narrative description of LVF consistent with moderate or severe systolic dysfunction.
Excludes:

• Patients less than 18 years of age • Patients transferred to another acute care hospital • Patients who left against medical advice • Patients discharged to hospice • Patients with chart documentation of participation in a clinical trial testing alternatives to ACEIs as first-line heart failure therapy • Patients with one or more of the following ACEI contraindications/reasons for not prescribing ACEI documented in the medical record: ƒ ACEI allergy; ƒ Moderate or severe aortic stenosis; ƒ Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing ACEI at discharge
(HF-4) Adult smoking cessation advice/counseling

Description: Heart failure patients with a history of smoking cigarettes, who are given
smoking cessation advice or counseling during hospital stay. For purposes of this measure, a
smoker is defined as someone who has smoked cigarettes anytime during the year prior to
hospital arrival.
Rationale: Smoking cessation is essential in patients with heart failure. Patients who receive
even brief smoking-cessation advice from their physicians are more likely to quit than those
who receive no counseling at all. Hospitalization can be an ideal opportunity for a patient to
stop smoking, and smoking cessation may promote the patient’s medical recovery.
Includes patients with:
• A history of smoking cigarettes anytime during the year prior to hospital arrival
Excluded Populations:
• Patients transferred to another acute care hospital • Patients who expired • Patients who left against medical advice
(PN-1) Oxygenation assessment

Description: Pneumonia patients who had an assessment of arterial oxygenation by arterial
blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the
hospital.
Rationale: Hypoxemia is a known risk factor for poor outcomes in patients with
pneumonia. Supplemental oxygen has been shown to decrease mortality in patients with
pneumonia.
Excludes:
• Patients received in transfer from another acute care or critical care access hospital, • Patients who have no working diagnosis of pneumonia at the time of admission • Patients receiving Comfort Measures Only
(PN-2) Pneumococcal screening and/or vaccination

Description: Pneumonia patients age 65 and older who were screened for pneumococcal
vaccine status and were administered the vaccine prior to discharge, if indicated.
Rationale: Pneumococcal vaccination is indicated for persons 65 years of age and older
because it is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It
is also an important vaccine due to increasing antibiotic resistance among pneumococci. In
the United States today, vaccine coverage is suboptimal. Although inpatient vaccine
screening and administration are recommended, hospitalization is an underutilized
opportunity for adult vaccination.
Excludes:
• Patients received in transfer from another acute care or critical access hospital, • Patients who left against medical advice • Patients who were discharged to a federal hospital • Patients who have no working diagnosis of pneumonia at the time of admission • Patients receiving Comfort Measures Only • Patients less than 65 years of age • Patients who were discharged to hospice care • Patients who were transferred to another short term general hospital for inpatient care (PN-3b) Blood cultures

Description: Collection of blood culture prior to first dose of antibiotic.
Rationale: Published pneumonia treatment guidelines recommend performance of blood
cultures for all inpatients to optimize therapy. Improved survival has been associated with
optimal therapy. In addition, the yield of clinically useful information is greater if the
culture is collected before antibiotics are administered.
Excludes:
• Patients received in transfer from another acute care or critical care access hospital, • Patients who have no working diagnosis of pneumonia at the time of admission • Patients receiving Comfort Measures Only • Patients having no blood cultures obtained
(PN-4) Adult smoking cessation advice/counseling

Description: Pneumonia patients with a history of smoking cigarettes who are given
smoking cessation advice or counseling during hospital stay.
Rationale: The publication “Treating Tobacco Use and Dependence, Quick Reference
Guide for Clinicians” states that tobacco use has been cited as the single greatest cause of
disease in the United States today. Smoking accounts for one out of every five deaths in the
United States and is the most important modifiable cause of premature death. The above-
mentioned Reference Guide for Clinicians also indicates that a high percentage of all
smokers (at least 70%) have expressed a desire to quit smoking. Smoking cessation
treatments ranging from brief clinician advice to specialist-delivered intensive programs,
including pharmacotherapy, are not only clinically effective, but also are extremely cost-
effective relative to other commonly used disease prevention interventions and medical
treatments. Hospitalization can be an ideal opportunity for a patient to stop smoking, and
smoking cessation may promote the patient’s medical recovery. Patients who receive even
brief smoking-cessation advice from their physicians are more likely to quit than those who
receive no counseling at all.

Includes patients with:
• A history of smoking cigarettes anytime during the year prior to hospital arrival
Excludes:
• Patients transferred to another acute care hospital • Patients received in transfer from another hospital’s emergency department • Patients who left against medical advice • Patients transferred to a federal hospital • Patients discharged to hospice • Patients who have no working diagnosis of pneumonia at the time admission • Patients receiving Comfort Measures Only
(PN-5) Antibiotic timing

Description: Timeliness of antibiotic administration for pneumonia inpatients.
Rationale: Population-based studies of pneumonia inpatients have demonstrated improved
severity-adjusted survival if the initial dose of antibiotic (IV, IM, PO, or NG) is
administered within eight hours of arrival at the hospital
Excludes:
• Patients received in transfer from another acute care hospital, including another • Patients who have no working diagnosis of pneumonia at the time of admission • Patients who do not receive antibiotics during hospitalization • Patients receiving Comfort Measures Only • Patients less than 18 years of age • Patients whose initial antibiotic was administered more than 2160 minutes (36 hours) • Patients who have received antibiotics within 24 hours prior to hospital arrival
(PN-5a) Initial Antibiotic Received within 8 Hours of Hospital Arrival.
(PN-5b) Initial Antibiotic Received within 4 Hours of Hospital Arrival.
(NQF-
ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
Description: PN 5a: Pneumonia patients who receive their first dose of antibiotics within 8
hours after arrival at the hospital.
PN 5b: Pneumonia patients who receive their first dose of antibiotics within 4 hours after
arrival at the hospital.
Rationale: There is growing clinical evidence of an association between timely inpatient
administration of antibiotics and improved outcome among pneumonia patients. One study
found that Medicare pneumonia patients had improved survival if they received antibiotics
within 4 hours of admission (Kahn 1990). Another study found that shortening the time-to-
first-dose to 4 hours was associated with improved survival (McGarvey 1993). In 1995 over
14,000 randomly selected Medicare pneumonia hospitalizations were examined. They
found that patients who received their first dose of antibiotic within 3 hours were less likely
to die within 30 days than were patients whose antibiotics were delayed, although this
association did not become statistically significant until 8 hours following arrival, when a
15% (P<0.001) reduction was noted (Meehan 1995). More recently, a study of 13,771
Medicare pneumonia hospitalizations from 1998-99 found that 30-day mortality was 10%
(P=0.04) lower and length of hospital stay was shorter among patients whose first antibiotic
was administered within 4 hours when compared with those whose time to first dose was
longer. Among patients who had not received antibiotics before arriving at the hospital,
administration within 4 hours was associated with 17% reductions in mortality during both
hospitalization (P=0.01) and the 30 days following admission (P=0.001) (Bratzler 2001).
Based on these studies, the Infectious Diseases Society of America (2000) and the American
Thoracic Society (2001) suggests 8 hours as the maximum time to first antibiotic
administration. Data collected by the National Pneumonia Project indicate that among
Medicare pneumonia patienst age 65 or older who were hospitalized during 1998-99, the
first dose was administered within 8 hours for 83.4%, within 6 hours for 74.9%, and within
4 hours for 57.7%. This represents a significant improvement from 1995, when
corresponding rates were 79.4% at 8 hours, 68.8% at 6 hours, and 49.9% at 4 hours (CMS
unpublished data). For 1998-99, the rates of administration within 8 hours ranged from 38%
to 91% among the states and territories.
Excludes:
• Patients received in transfer from another acute care or critical access hospital, • Patients who had no working diagnosis of pneumonia at the time of admission • Patients who do not receive antibiotics during hospitalization • Patients who received Comfort Measures Only • Patients whose initial antibiotic was administered more than 2160 minutes (36 hours) • Patients who have received antibiotics within 24 hours prior to hospital arrival
(PN-6a) Initial antibiotic selection for Community- Acquired Pneumonia (CAP)
in immunocompetent patients – Intensive Care Unit (ICU) patients
.
Description: Immunocompetent ICU patients with CAP who receive an initial antibiotic
regimen during the first 24 hours that is consistent with current guidelines.
Rationale: The current North American antibiotic guidelines for CAP in immunocompetent
patients are from the Centers for Disease Control and Prevention (CDC), the Infectious
Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian
Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS). All four reflect
that Streptococcus pneumoniae is the most common cause of PN, that treatment that covers
“atypical” pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma
pneumoniae) can be associated with improved survival, and that the prevalence of antibiotic
resistant S. pneumoniae is increasing.
The CMS convened a conference of guideline authors, including Julie Gerberding, MD
(CDC), John Bartlett, MD (IDSA), Ronald Grossman, MD (IDSD/CTS), and Michael
Niederman, MD (ATS), to reach consensus on the antibiotic regimens that could be
considered consistent with all four organizations’ guidelines. These regimens are reflected
in this measure, and in the Pneumonia Antibiotic Consensus Recommendation which
follows later in this section.
Numerator Includes: ICU PN patients on the following antibiotics:
• IV Beta-Lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus IV Macrolide • IV Beta-Lactam plus Quinolone IV (levofloxacin, gatifloxacin, moxifloxacin) • If documented beta-lactam allergy: IV Quinolone plus IV Clindamycin or IV • For patients with pseudomonal risk the following antibiotics should be used: o IV antipseudomonal β-lactam (cefepime, imipenem, meropenem, piperacillin-tozobactam) plus IV antipseudomonal quinolone (ciprofloxacin, levofloxacin), OR o IV antipseudomonal β-lactam and IV aminoglycoside (gentamicin, tobramycin, amikacin) plus either an IV antipneumococcal quinolone (levofloxacin, gatifloxacin, moxifloxacin) or IV macrolide (azithromycin, erythromycin) o If documented beta-lactam allergy: Aztreonam IV plus IV Aminoglycoside
Excludes:
• Patients received in transfer from another acute care or critical access hospital, • Patients who have no Working Diagnosis of pneumonia at the time of admission • Patients receiving Comfort Measures Only • Patients who are Compromised as defined in the Data Dictionary • Patients who have initial antibiotic more than 36 hours from the time of arrival • PN patients not in the ICU • Patients who do not receive antibiotics during hospitalization (PN-6b) Initial antibiotic selection for Community-Acquired Pneumonia (CAP)
in immunocompetent patients – Non intensive care unit patients.

Description: Immunocompetent non-Intensive Care Unit (ICU) patients with CAP who
receive an initial antibiotic regimen during the first 24 hours that is consistent with current
guidelines.
Rationale: The current North American antibiotic guidelines for PN in immunocompetent
patients are from the Centers for Disease Control and Prevention (CDC), the Infectious
Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian
Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS). All four reflect
that Streptococcus pneumoniae is the most common cause of PN, that treatment that covers
“atypical” pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma
pneumoniae) can be associated with improved survival, and that the prevalence of antibiotic
resistant S. pneumoniae is increasing.

The CMS convened a conference of guideline authors, including Julie Gerberding, MD
(CDC), John Bartlett, MD (IDSA), Ronald Grossman, MD (IDSD/CTS), and Michael
Niederman, MD (ATS), to reach consensus on the antibiotic regimens that could be
considered consistent with all four organizations’ guidelines. These regimens are reflected
in this measure, and in the Pneumonia Antibiotic Consensus Recommendation which
follows later in this section.
Numerator Includes: Non-ICU patients on the following antibiotics:
• Beta-Lactam IV or IM (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus IV or oral Macrolide (erythromycin, clarithromycin, azithromycin). OR • Quinolone monotherapy IV or oral (levofloxacin, gatifloxacin, moxifloxacin) • Beta-Lactam IV or IM plus doxycycline IV or Oral.
Excludes:
• Patients received in transfer from another acute care or critical access hospital • Patients who had no Working Diagnosis of pneumonia at the time of admission • Patients who received Comfort Measures Only • Patients who are Compromised as defined in the Data Dictionary • Patients who have initial antibiotic more than 36 hours from the time of arrival • Pneumonia patients in the ICU • Patients who do not receive antibiotics during hospitalization
(PN-7) Influenza Vaccination

Description: Pneumonia patients age 50 years and older, hospitalized during October,
November, December, January, or February who were screened for influenza vaccine status
and were vaccinated prior to discharge, if indicated.
Rationale: Influenza vaccination is indicated for people age 50 years and older because it is
highly effective in preventing influenza-related pneumonia, hospitalization, and death.
Vaccine coverage in the United States is suboptimal. Screening and vaccination of
inpatients is recommended, but hospitalization is an underutilized opportunity to provide
vaccination to adults.
Excludes:
• Patients received in transfer from another acute care or critical access hospital • Patients who had no Working Diagnosis of pneumonia at the time of admission • Patients who received Comfort Measures Only • Patients who expired in the hospital • Patients who left the hospital against medical advice (AMA) • Patients who were discharged to hospice care • Patients with a principal or secondary diagnosis of 487.0 (influenza with pneumonia) • Patients who were transferred to another short term general hospital for inpatient care, or who were discharged/transferred to a federal hospital

Source: http://www.saintfranciscare.net/saintfrancisdoctors/quality/coreMeasures.pdf

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