Home » Bloodstream Infection Present on Admission
Print this page

Release Notes:
Data Element
Version 2013B

Data Element Name: Bloodstream Infection Present on Admission
Collected For: PC-04,
Definition:Documentation in the medical record that the patient had a bloodstream infection present on admission.This includes both patients with postive blood cultures or negative or inconclusive blood cultures when the patient is suspected of having a bloodstream infection or septicemia and is being treated for the condition. A blood culture can be defined as a culture of microorganisms from specimens of blood to determine the presence and nature of bacteremia.
Suggested Data Collection Question:Is there documentation that the patient had a bloodstream infection present on admission or is receiving treatment for a suspected bloodstream infection or septicemia on admission?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation that the patient had a bloodstream infection present on admission or is receiving treatment for a suspected bloodstream infection or septicemia on admission.

N (No) There is no documentation that the patient had a bloodstream infection present on admission or is receiving treatment for a suspected bloodstream infection or septicemia present on admission or unable to determine from medical record documentation.

Notes for Abstraction:The admission assessment and the NICU admission assessment or notes should be reviewed first for documentation of a suspected or confirmed bloodstream infection present on admission. Documentation of the suspected bloodstream infection being present on admission should be taken at face value regardless of the blood culture results. Birth is considered the same as admission for patients who were born in the reporting hospital. If the present on admission (POA) indicator is present with the ICD-9-CM diagnosis code for septicemia or bacteremia, answer “yes” to bloodstream infection present on admission.
Suggested Data Sources:

  • History and physical
  • Laboratory report
  • Nursing notes
  • Nursing admission assessment
  • Progress notes
  • Admission assessment
  • Microbiology report
  • NICU admission assessment or notes

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Suspected bloodstream infection
  • Positive blood culture
  • Negative or inconclusive blood culture under treatment
  • Staphylococcal septicemia
  • Staphylococcal bacteremia
  • Gram negative septicemia
  • Gram negative bacteremia

  • None

Bloodstream Infection Present on Admission
Specifications Manual for Joint Commission National Quality Measures (v2013B)
Discharges 07-01-13 (3Q13) through 12-31-13 (4Q13)