Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

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 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.

Regardless of the blood culture results, if there is documentation by the clinician specifically stating that a suspected bloodstream infection was present on admission, this should be taken at face value, select "yes".

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.

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 there is documentation that a course of antibiotics was started within the first 48 hours after admission which lasted less than 7 days, select allowable value “no”.
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 (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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