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

Data Element Name: Bloodstream Infection Confirmed
Collected For: PC-04
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.
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?
Format:
Length:1
Type:Alphanumeric
Occurs:1
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.
Notes for Abstraction:Confirmation of BSI is based on Bloodstream Infection Event criteria from the Centers for Disease Control and Prevention (CDC) available at: https://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html

Hospital infection prevention and control professionals should be consulted to assist with confirmation of BSI.

For patients who die or transfer to another facility prior to the completion of a 7 day course of antibiotics, when there is a confirmed BSI and a 7 day course of antibiotics was planned, select Yes.
Suggested Data Sources:

  • History and physical
  • Laboratory report
  • Nursing notes
  • Progress notes
  • Microbiology report
  • NICU notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • 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

Bloodstream Infection Confirmed
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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