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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Blood Culture Collected

Release Notes:
Data Element
Version 2015A

Data Element Name: Blood Culture Collected
Collected For: PN-3a,
Definition:Documentation in the medical record that a blood culture was collected the day prior to arrival, the day of arrival, or within 24 hours after arrival to the hospital. This includes blood cultures drawn in the emergency room or in observation beds prior to admission order, as well as after the patient's admission to inpatient status. 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:Did the patient have blood cultures collected the day prior to arrival, the day of arrival or within 24 hours after hospital arrival?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1   Initial blood culture collected in the ED prior to admission order.

2   Initial documentation of the blood culture collected during this hospitalization but after admission order for ED patients (or within 24 hours after arrival for Direct Admits).

3   Documentation that the patient had a blood culture collected the day prior to arrival or the day of arrival up until the time of presentation to the hospital.

4   The patient did not have a blood culture collected the day prior to arrival, the day of arrival or within 24 hours after arrival or unable to determine from medical record documentation.

Notes for Abstraction:
  • If the ED patient had initial documentation of a blood culture collected as an ED patient (regardless of location e.g. sent to radiology for tests) prior to an admission order (Observation or Inpatient), select "1."” If a patient was held in the ED for a period of time following an admission order, and the initial documentation of a blood culture was collected while the patient was still in the ED but following the admission order, select "2.”"
  • If a blood culture is ordered and there is an attempt to collect it, but the attempt results in failure to collect the specimen (too dehydrated to get a vein) or the specimen was contaminated during or after the draw, select "“1"” or “"2.”"
  • For the purposes of this measure, a patient is no longer considered an ED patient after the admission order is written, regardless of location.
  • If there are multiple admit orders, use the initial (earliest) one for this data element. For the purposes of this data element, any form of physician admit order can be used to determine admission time. This includes written physician order, nurse documentation of physician order (verbal or telephone), disposition or status change to admit.
  • If no blood cultures are collected within 24 hours after arrival to the hospital, select "“4."”
  • If it is evident a blood culture was performed after arrival to the hospital but from medical record documentation you are unable to determine if the blood culture was performed in the ED prior to admission or performed after admission, select "“2."”
  • For patients with documentation of blood cultures performed the day prior to arrival or the day of arrival prior to presentation to hospital AND within 24 hours after arrival to the hospital, select value "“3."”
  • If there is supportive documentation that a blood culture was collected and it is the earliest mention of a blood culture, this date and time can be used, e.g., “"BC sent to lab,"” "“blood culture received time.”"
  • Do not use physician orders to determine a blood culture was collected, as they do not demonstrate collection of the blood culture.
  • Documentation must specify blood culture.
    Example:
    "“lab was at bedside- blood drawn"” (does not demonstrate blood culture).
Suggested Data Sources:

  • Emergency department record
  • History and physical
  • Laboratory report
  • Nursing notes
  • Progress notes
  • Microbiology report
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

  • BC
  • Blood cultures
  • Blood cultures collected on patients in observation beds.
  • Initial documentation of a blood culture collected within 24 hours after arrival to the hospital

  • Cultures collected more than 1 day prior to arrival
  • Initial documentation of a blood culture collected more than 24 hours after arrival to the hospital

Blood Culture Collected
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
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