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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Initial Blood Culture Collection Time

Release Notes:
Data Element
Version 2015A

Data Element Name: Initial Blood Culture Collection Time
Collected For: PN-3a,
Definition:The time (military time) that the initial documentation of a blood culture was collected within 24 hours after hospital arrival. 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:What is the time of the initial documentation of a blood culture collected within 24 hours after hospital arrival?
Format:
Length:5 - HH:MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format.
With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:
Midnight - 00:00      Noon - 12:00
5:31 am - 05:31      5:31 pm - 17:31
11:59 am - 11:59     11:59 pm - 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Initial Blood Culture Collection Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.
When converting 24:00 to 00:00 do not forget to change the Initial Blood Culture Collection Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “"seconds,"” remove the seconds and record the time as is.
    Example:
    15:00:35 would be recorded as 15:00.
  • If the blood culture collection time is unable to be determined from medical record documentation, select "“UTD.”"
  • The medical record must be abstracted as documented (taken at “"face value"”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select "“UTD."”
    Example:
    Documentation indicates the Initial Blood Culture Collection Time was 3300. No other documentation in the medical record provides a valid time. Since the Initial Blood Culture Collection Time is outside of the range listed in the Allowable Values for “"Hour,"” it is not a valid time and the abstractor should select "“UTD."”
    Note: Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’'s Data Warehouse. Use of "“UTD”" for Initial Blood Culture Collection Time allows the case to be accepted into the warehouse.
  • 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, enter the time of the attempted blood culture collection.
  • If multiple times of collection are documented abstract the earliest (initial) time, providing documentation demonstrates collection.
  • Only collect times for blood cultures within 24 hours after hospital arrival.
  • 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 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 within 24 hours after hospital arrival
  • Blood cultures within 24 hours after hospital arrival

  • Cultures collected prior to arrival

Initial Blood Culture Collection Time
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
Questions? Ask Question to Joint Commission staff Copyright © 2014 by The Joint Commission.
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