Release Notes:
Data Element
Version 2015B1
| Data Element Name: | Bloodstream Infection Confirmed |
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| Collected For: | PC-04, |
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| Definition: | Documentation in the medical record that the bloodstream infection (BSI) is confirmed after the first 48 hours after admission. This includes patients with positive blood cultures or inconclusive blood cultures when the patient is suspected of having a bloodstream infection or septicemia and is being treated with a course of antibiotics for 7 days or longer 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. |
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| Suggested Data Collection Question: | Is there documentation after the first 48 hours after admission that the patient has a bloodstream infection and was receiving a course of antibiotics for 7 days or longer for a suspected bloodstream infection or septicemia? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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|
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| Allowable Values: |
Y (Yes) There is documentation that the bloodstream infection (BSI) is confirmed after the first 48 hours after admission and is being treated with a course of antibiotics for 7 days or longer for the condition.
N (No) There is no documentation that the bloodstream infection (BSI) is confirmed after the first 48 hours after admission and is being treated with a course of antibiotics for 7 days or longer for the condition or unable to determine from medical record documentation.
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| Notes for Abstraction: | Confirmation of BSI is based on criteria from the Centers for Disease Control and Prevention (CDC) available at: http://www.cdc.gov/nhsn/inpatient-rehab/clabsi/ |
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| Suggested Data Sources: |
- History and physical
- Laboratory report
- Nursing notes
- Progress notes
- Microbiology report
- NICU notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
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- Suspected, presumed or rule out bloodstream infection without a positive blood culture
- Receiving a course of antibiotics primarily for the following conditions:
- Diagnosis of necrotizing enterocolitis (NEC)
- Diagnosis of urosepsis
- Skin infections confirmed as the primary source of the BSI
- Diagnosis of pneumonia
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Bloodstream Infection Confirmed
Specifications Manual for Joint Commission National Quality Measures (v2015B1)
Discharges from 10/01/2015 to 06/30/2016
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