• If the date an antibiotic is administered is unable to be determined from medical record documentation, enter “UTD”.
• The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid format/range or outside of the parameter of care [after the Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
  Examples:
  • Documentation indicates the Antibiotic Administration Date was on 02- 42 -2008. No other documentation in the medical record provides a valid date. Since the Antibiotic Administration Date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD.”
  • Patient expires on 02-12-2008 and documentation indicates the Antibiotic Administration Date was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”
    Note:
    Transmission of a case with an invalid date as described above, will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Antibiotic Administration Date allows the case to be accepted into the warehouse.
• Collect only antibiotics administered via an appropriate route (SCIP-Inf: PO and IV; PN: PO, IV and IM) to answer this question.
• The use of “hang time” or “infusion time” is acceptable as antibiotic administration time when other documentation cannot be found.
• If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered.
• Only use “Antibiotic NOS” in the following situations:
  • For new antibiotics that are not yet listed in Table 2.1
  • When there is documentation an antibiotic was administered but unable to identify the name. It must be apparent that the medication is an antibiotic.
    Example:
    -On 2-12-08, the ED record contains the documentation, “Antibiotic started name illegible, 2gm, IV, 0200-JM”. In the antibiotic grid, “Antibiotic NOS” would be entered for the name, IV for the route, 0200 for the time and 2-12-08 for the date. (If “Antibiotic started” had not been documented in this example, the medication could not be abstracted as an Antibiotic Received.
• A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG and Other Cardiac Surgery] for SCIP-Inf) record the antibiotic name once for each route by which it was administered.
  Example:
  • A patient arrives at the hospital at 07:15 on 05-05-2007. Zithromax IV is administered in the ED at 09:30 on 05-05-2008. On 05-06-2007 at 09:00, Zithromax PO is recorded as administered on the MAR.
    Enter: Zithromax 05-05-2007, 09:30, IV and Zithromax 05-06-2007, 09:00, PO.
• Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic, enter an Antibiotic Administration Route, Date and Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilize “UTD” for the missing information.
  Example:
  • The signed and dated anesthesia record contains the documentation: “Ancef 1 gm at 10:50”. The route is missing from this documentation. Enter “UTD” for the route in this grid entry. Do not use the operative report that contains documentation of the route to collect the missing information from the anesthesia record.
• Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic.
  Examples:
  • Do not use physician orders as they do not demonstrate administration of the antibiotic (in the ED this may be used if signed/initialed by a nurse).
  • In narrative documentation, only accept documentation that reflects the actual administration of the antibiotic.
• The date of administration must be documented on each side of every page used as a data source. If this is not the case, utilize “UTD” for the missing date.
• If an ED form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for ED documentation only. If this is not the case, utilize “UTD” for the missing date.
• Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic.

SCIP-Inf:

• First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Surgery End Time (72 hours postop for CABG or Other Cardiac Surgery).
• Second: Abstract the dose administered prior and closest to Surgical Incision Time.
  Example:
  • Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered at 15:30 and 17:00.
    Abstract:
    - Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
    - Antibiotic B: 15:30 (first) and 17:00 (last)
    
    Notes:
  • This data element has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery). However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable.
  • In addition to abstracting the specific doses with non-UTD values for Antibiotic Administration Time or Antibiotic Administration Date that satisfy the requirements for either of the approaches for abstraction:
    1. All doses documented without a date should be abstracted with “UTD” for Antibiotic Administration Date as it can’t be determined if the dose(s) falls into the guidelines for either of these approaches.
    2. All doses documented without a time but with a non-UTD Antibiotic Administration Date should be abstracted with “UTD” Antibiotic Administration Time if you are unable to determine if the dose(s) falls into the guidelines for either of these approaches.
       Example:
    • Surgery Start Date was 04-01-2008. Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered 04-01-2008 at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered 04-01-2008 at 11:00 and also 04-01-2008 without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date. Abstract the doses administered at the following times:
      - Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
      - Antibiotic B: 11:00 (first) and UTD (without an administration time it can’t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose)
      - Antibiotic C: 11:30 (without an administration date, it can’t be determined if this dose was first, prior and closest to Surgical Incision Time, or the last dose)

NOTE TO PROGRAMMERS:
The objective is to give systems the flexibility to reduce the number of antibiotic doses abstracted, without substantial changes to their existing systems. At the time of data entry, systems may choose to provide onscreen guidance as to the equivalence of a given set of generic and trade names.

PN:

• Document the initial (first time) month, day, and year, for which the patient received each antibiotic administered during the first 24 hours after hospital arrival.
• If an antibiotic is given more than one time during the first 24 hours after hospital arrival, only record the antibiotic name once. Enter the first administration date and time associated with each antibiotic name.
  Note:
  In addition to abstracting the specific doses with non-UTD values for Antibiotic Administration Time or Antibiotic Administration Date that were administered within the first 24 hours after hospital arrival:
  1. All doses documented without a date should be abstracted with “UTD” for Antibiotic Administration Date as it can’t be determined if the dose(s) were administered within the first 24 hours after hospital arrival.
  2. All doses documented without a time but with a non-UTD Antibiotic Administration Date should be abstracted with “UTD” Antibiotic Administration Time if you are unable to determine if the dose(s) were administered within the first 24 hours after hospital arrival.
     Example:
  • Arrival Date was 04-01-2008. Arrival Time was 06:00. Antibiotic A was administered 04-01-2008 at 08:00, 14:00, and 22:00. Antibiotic B was administered 04-02-2008 without a documented administration time. Antibiotic C was administered at 11:30 without a documented administration date, and 04-03-2008 at 09:00. Abstract the doses administered at the following times:
    - Antibiotic A: 08:00 (first dose within 24 hours after arrival)
    - Antibiotic B:UTD (without an administration time, it can’t be determined if this dose was within the first 24 hours after arrival)
    - Antibiotic C: 11:30 (without an administration date, it can’t be determined if this dose was within the first 24 hours after arrival)

For SCIP-Inf, in addition to the above suggested data sources, the following may also be utilized:

• Anesthesia record
• Operating room record
• PACU/recovery room record