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Measure Information Form
Version 2010A1


Measure Information Form

Measure Set: Pneumonia(PN)

Set Measure ID: PN-5b

Performance Measure Name: Initial Antibiotic Received Within 4 Hours of Hospital Arrival

Description: Pneumonia patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital

Rationale: Time to first antibiotic dose for CAP has recently received significant attention from a quality-of care perspective. This emphasis is based on 2 large retrospective studies of Medicare beneficiaries that demonstrated statistically significantly lower mortality among patients who received early antibiotic therapy (Meehan, Houck). The initial study by Meehan demonstrated a 15% relative reduction in 30-day mortality when antibiotics were administered within a 8 hours of arrival, whereas the subsequent analysis by Houck et al found that delivery of antibiotics within 4 hours was associated with lower mortality 30-day mortality (15% relative reduction). The studies differed in that Houck and colleagues excluded patients who were on antibiotics prior to hospital arrival. Several small prospective studies that document the time to first antibiotic dose do not consistently demonstrate this reduction in 30-day mortality, although none had as large a patient population as those in the studies of Meehan and Houck. The IDSA/ATS guideline committee did recommend that antibiotic therapy should be administered as soon as possible after the diagnosis of pneumonia is considered likely and specifically state that delivery of first antibiotic dose would be expected within 6–8 h of presentation whenever the admission diagnosis is likely CAP.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Number of pneumonia patients who received their first antibiotic dose within a specified timeframe (as specified under the Set Measure Identifier and description above) from hospital arrival
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Pneumonia patients 18 years of age and older

Included Populations: Discharges 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
  • 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 with Diagnostic Uncertainty as defined in the Data Dictionary
  • 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 another federal health care facility on day of or day after arrival
  • Patients who do not receive any antibiotics within 24 hours after arrival or who received antibiotics the day of arrival (prior to arrival to the hospital) or the day prior to arrival

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. 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 and other ICD-9-CM diagnosis and procedure codes, which require retrospective data entry.

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

  • Health care organizations may want to work with their hospital pharmacy to identify and list the antibiotics that are used in their organization. This list can serve as a reference for the abstractor.
  • To be part of the measure population, a patient must have received an antibiotic during the hospitalization.
  • The date and time for the initial antibiotic refer to the initial antibiotic administered during the hospital stay, not the antibiotic taken prior to hospital arrival.

Measure Analysis Suggestions: Health care organizations should investigate any patients whose time to antibiotic administration was greater than 1440 minutes (24 hours) for a possible data entry error or a performance improvement opportunity.

This measure seeks to identify the timing of the first antibiotic administered. It is important to note that the measure focuses on the administration of any antibiotic, not necessarily the antibiotic consistent with consensus guidelines. Therefore, data from this measure should be reviewed in conjunction with PN-6, PN-6a, and PN-6b that address appropriate antibiotic selections. For example, an HCO could receive excellent indicator rates for antibiotic administered timing but low rates for giving the appropriate antibiotics consistent with guidelines.

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

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

Selected References:

  • Bratzler, DW, Houck PM, Nsa W, et al. Initial processes of care and outcomes in elderly patients with pneumonia. {abstract} American College of Emergency Physicians Research Forum, October 15, 2001, Chicago, IL.
  • Heffelfinger JD, Dowell SF, Jorgensen JH, Klugman KP, Mabry LR, Musher DM, Plouffle JF, Rakowsky A, Schuchat A, Whitney C and the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group, “Management of Community-Acquired Pneumonia in the Era of Pneumococcal Resistance: A Report From the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group.” Arch Intern Med, 160:1399-1408, May 22, 2000.
  • Houck PM, Bratzler DW, Nsa W, et al. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004; 164: 637-644.
  • Khan KL, Rogers WH, Rubenstein LV, et al. Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system. JAMA. 1990:264:1969-1973.
  • 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.
  • McGarvey RN, Harper JJ. Pneumonia mortality reduction and quality improvement in a community hospital. Qual Rev Bull. 1993;19:124-130.
  • Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process and outcomes in elderly patients with pneumonia. JAMA. 1997;278:2080-2084.

Measure Algorithm:

Attach file

Related Topics

Measure Information Form PN-5b
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)