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Release Notes:
Data Element
Version 2010A1

Data Element Name: Vancomycin
Collected For: SCIP-Inf-2,
Definition:The documented rationale for using vancomycin as antimicrobial prophylaxis.
Suggested Data Collection Question:What reason was documented for using vancomycin?
Format:
Length:2
Type:Alphanumeric
Occurs:1-10
Allowable Values:

Select all that apply:

1    Documentation of beta-lactam (penicillin or cephalosporin) allergy

2   Physician/APN/PA or pharmacist documentation of MRSA colonization or infection.

3   Documentation of patient being high-risk due to acute inpatient hospitalization within the last year

4   Documentation of patient being high-risk due to nursing home or extended care facility setting within the last year, prior to admission

5   Physician/APN/PA or pharmacist documentation of increased MRSA rate, either facility-wide or operation-specific

6   Physician/APN/PA or pharmacist documentation of chronic wound care or dialysis

7   Documentation of continuous inpatient stay more than 24 hours prior to the principal procedure

8   Other physician/APN/PA or pharmacist documented reason

9   No documented reason/Unable to Determine

10   Physician/APN/PA or pharmacist documentation of patient undergoing valve surgery

11   Documentation of patient being transferred from another inpatient hospitalization after a 3-day stay

JOINT COMMISSION NOTE TO PROGRAMMERS:
Measurement systems should implement validation rules in their data collection tools such that an allowable value of 9, “No documented reason” overrides all other entries for this data element. Therefore, a maximum of 10 entries should be recorded.

Notes for Abstraction:
  • For this data element, documentation by an infection control practitioner is acceptable (in addition to physician/APN/PA or pharmacist documentation) if it is specifically designated as “infection control” documentation. An infection control practitioner may be a medical technician, nurse, physician/APN/PA, or pharmacist.
    Examples:
    • In the progress notes, it is documented, “Patient has a history of MRSA” and it is signed by Nancy Nurse, RN, CIC.
    • In the progress notes, under the heading “Infection Control,” a physician/APN/PA or pharmacist documents that vancomycin is used because of the hospital’s high MRSA rate.
  • Physician/APN/PA, pharmacist or infection control practitioner documentation of the reason for the use of Vancomycin as prophylaxis must have been entered into the medical record preoperatively to select Allowable Values 2, 5, 6, 8, and 10. If the documentation was not entered preoperatively, select Value 9- No documented reason/Unable to Determine.
  • In order to select allowable value #1 “Documentation of beta-lactam (penicillin or cephalosporin) allergy,” the answer to the data element Antibiotic Allergy must be “Yes.”
  • If the medical record contains preprinted orders (signed by a physician) prescribing vancomycin for all valve surgeries, select allowable value #10.
Suggested Data Sources:

WHERE SPECIFIED IN ALLOWABLE VALUES ABOVE, PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION ONLY IS ALLOWED.

  • Anesthesia record
  • Emergency department record
  • History and Physical
  • ICU flowsheet
  • IV flowsheet
  • Medication administration record
  • Nurses notes
  • Operating room record
  • PACU/recovery room record
  • Physician’s orders
  • Progress notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Hospitalization
  • Acute inpatient
  • Federal or VA facility
  • Hospice- Acute facility
  • Long-term care hospital
  • Inpatient rehabilitation unit or facility
  • Inpatient drug rehabilitation

Nursing Home or Extended Care Facility

  • Hospice- Skilled/Respite
  • Intermediate care facility (ICF)
  • Respite care
  • Skilled nursing facility (SNF) or SNF rehabilitation unit
  • Sub-acute care
  • Swing bed/unit
  • Transitional care unit (TCU)

  • Assisted Living
  • Board and Care
  • Group home/personal care homes
  • Residential care
  • Residential or outpatient chemical dependency treatment
  • Psychiatric unit or facility
  • Hospice at home

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