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Release Notes:
Data Element
Version 2010A1

Data Element Name: Identified Pathogen
Collected For: PN-6, PN-6a, PN-6b,
Definition:Documentation that results of a positive culture or diagnostic test for a pathogen were available upon arrival or within 24 hours after arrival to the hospital. For the purposes of this measure, a positive diagnostic test for a pathogen is defined as any of the following:
  • Known positive culture (blood, urine, sputum, wound, etc.)
  • Positive urinary antigen test for Streptococcus pneumoniae or Legionella pneumophilia
  • Positive Polymerase Chain Reaction (PCR) test for Legionella pneumophilia
Suggested Data Collection Question:Is there documentation that results of a positive culture or diagnostic test for a pathogen were available upon arrival or within 24 hours after arrival to the hospital?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation that results of a positive culture or diagnostic test for a pathogen were available upon arrival or within 24 hours after arrival to the hospital.

N   (No)   There is no documentation that results of a positive culture or diagnostic test for a pathogen were available upon arrival or within 24 hours after arrival to the hospital or unable to determine from medical record documentation.

Notes for Abstraction:
  • If a culture is drawn prior to arrival or within 24 hours of arrival but results documenting a pathogen are not available within 24 hours of arrival, - Select “No.”
  • Gram stain results alone are not acceptable – a pathogen must be identified.
    Example:
    Sputum reveals gram positive cocci, but an organism has not been identified, - Select “No.”
  • Any physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation of a known pathogen within 24 hours of arrival, - Select “Yes”
    Example:
    Physician documents in the ED H&P, “chronic history of pseudomonas”
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Laboratory report
  • Progress notes
  • Physician orders
  • Admitting physician orders
  • Physician admitting note
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • Tests collected/drawn but not available/reported within 24 hours after arrival to the hospital
  • Gram stain results that do not list a pathogen
    Examples:
    • gram stain
    • positive cocci
    • Gram negative rods
    • normal flora

Identified Pathogen
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)