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Release Notes:
Measure Information Form
Version 2010A1


Measure Information Form

Measure Set: Pneumonia(PN)

Set Measure ID: PN-3a

Performance Measure Name: Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival

Description: Pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival.

Rationale: Published pneumonia treatment guidelines from ATS/IDSA recommend performance of blood cultures for all inpatients with severe pneumonia to optimize therapy. Improved survival has been associated with optimal therapy. In addition, the yield of clinically useful information is greater if the culture is collected before antibiotics are administered. The actual performance of a culture has been added to this measure because restricting measurement to culture collection prior to antibiotics provides an incentive for hospitals not to perform a culture in any patient who has already received antibiotics.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Number of pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival who had blood cultures performed within 24 hours prior to or 24 hours after arrival at the hospital
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Pneumonia ICU patients 18 years of age and older

Included Populations: Discharges:
  • Who are transferred or admitted to the ICU within 24 hours of hospital arrival
  • With an ICD-9-CM Principal Diagnosis Code of pneumonia as defined in Appendix A, Table 3.1 OR ICD-9-CM Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) as defined in Appendix A, Tables 3.2, or 3.3
    AND
  • With an ICD-9-CM Other Diagnosis Code of pneumonia (Appendix A, Table 3.1)

Excluded Populations:

  • Patients less than 18 years of age
  • Patients who have a Length of Stay >120 days
  • Patients with Cystic Fibrosis (Appendix A, Table 3.4)
  • Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization
  • Patients with Comfort Measures Only documented on day of or day after arrival
  • Patients enrolled in clinical trials
  • Patients received as a transfer from the emergency department of another hospital
  • Patients received as a transfer from an acute care facility where they were an inpatient or outpatient
  • Patients received as a transfer from one distinct unit of the hospital to another distinct unit of the same hospital
  • Patients received as a transfer from an ambulatory surgery center
  • Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression
  • Patients not transferred or admitted to the ICU within 24 hours of hospital arrival
  • Patients discharged/transferred to another hospital for inpatient care on day of or day after arrival
  • Patients who left against medical advice or discontinued care on day of or day after arrival
  • Patients who expired on day of or day after arrival
  • Patients discharged/transferred to a federal health care facility on day of or day after arrival

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective, data sources for required data elements include administrative data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-9-CM diagnosis and procedure codes, which require retrospective data entry.

Model Validation:

Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

  • Heffelfinger JD, Dowell SF, Jorgensen JH, Klugman KP, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the Drug-Resistant Streptococcus Pneumoniae Therapeutic Working Group. Archives of Internal Medicine. 2000, 160:1399-1408.
  • Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Clin Infect Dis 2000;31:383-421.
  • Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
  • Metersky ML, Ma A, Bratzler DW, et al. Predicting bacteremia in patients with community-acquired pneumonia. Am J Respir Crit Care Med 2004; 169: 342-347

Measure Algorithm:

Attach file

Related Topics

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