Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Infection Prior to Anesthesia |
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| Collected For: | SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7, |
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| Definition: | Documentation the patient had an infection during this hospitalization prior to the principal procedure.
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| Suggested Data Collection Question: | Did the patient have an infection during this hospitalization prior to the principal procedure? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) Physician/advanced practice nurse/physician assistant (physician/APN/PA documentation that the patient had an infection during this hospitalization prior to the principal procedure.
N (No) There is no physician/APN/PA documentation that the patient had an infection during this hospitalization prior to the principal procedure, or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If there is preoperative documentation of an infection or possible/suspected infection, select “Yes.”
- Documentation of symptoms (example: fever, elevated white blood cells, etc.) should not be considered infections unless documented as an infection or possible/suspected infection.
Example:
Do not assume infection if a wound/surgical site is described as reddened, swollen and hot, as other conditions can also cause these symptoms.
- The physician/APN/PA documentation of preoperative infection must be in place prior to surgery. Do not accept documentation of a preoperative infection documented any time after Surgical Incision Time.
- H&Ps dated prior to arrival must reflect that an infection or possible/suspected infection is current.
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| Suggested Data Sources: |
PHYSICIAN/APN/PA DOCUMENTATION ONLY
- Anesthesia record
- History and physical
- Progress notes
Excluded Data Sources:
Any documentation of an infection found in the Operative Report
Note:
Do NOT use Table 5.09 as a reference for Infection Prior to Anesthesia. This data element has an inclusion table to use as a guideline that provides the types of infection that are acceptable. Please reference this inclusion table when answering this data element. |
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Abscess
- Acute abdomen
- Bloodstream infection
- Bone infection
- Cellulitis
- Gangrene
- Fecal Contamination
- H. pylori
- Necrotic/ischemic/infarcted bowel
- Osteomyelitis
- Other documented infection
- Penetrating abdominal trauma
- Pneumonia or other lung infection
- Sepsis
- Surgical site or wound infection
- Urinary tract infection (UTI)
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- Colonized MRSA
- History (Hx) of MRSA
- Viral infections
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Infection Prior to Anesthesia
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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