Bloodstream Infection Present on Admission

Specifications Manual for Joint Commission National Quality Measures (v2015A1)

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Release Notes:
Data Element
Version 2015A1

Data Element Name:

Bloodstream Infection Present on Admission

Collected For:

PC-04,

Definition:

Documentation in the medical record within the first 48 hours after admission that the patient had a bloodstream infection present on admission. This includes patients with positive 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 within the first 48 hours after admission 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 within the first 48 hours after admission 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 within the first 48 hours after admission 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 NICU notes should be reviewed first for documentation of a suspected or confirmed bloodstream infection present on admission or within the first 48 hours after admission. Documentation of the suspected bloodstream infection being present on admission should be taken at face value regardless of the blood culture results.

Routine work up for sepsis for high risk newborns admitted to the NICU should not be considered a suspected bloodstream infection in the absence of positive blood culture results. There must be documentation from the clinician specifically stating that the newborn appeared septic or was showing signs and symptoms of sepsis in order to answer yes. Signs and symptoms of sepsis include but are not limited to: body temperature changes, respiratory difficulty, diarrhea, hypoglycemia, reduced movements, reduced sucking, seizures, bradycardia, swollen/distended abdomen, vomiting and/or jaundice.

The results of the initial blood cultures drawn within the first 48 hours of admission which are reported after the first 48 hours may be used to determine if the bloodstream infection was present on admission.

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 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
Inconclusive blood culture under treatment
Staphylococcal septicemia
Staphylococcal bacteremia
Gram negative septicemia
Gram negative bacteremia

Rule out sepsis
R/O sepsis
Work up for sepsis
Negative blood culture under treatment
Evaluation for sepsis

Bloodstream Infection Present on Admission

Specifications Manual for Joint Commission National Quality Measures (v2015A1)
01/01/2015 - 09/30/2015