Release Notes:
Data Element
Version 2010B
| Data Element Name: | Antibiotic Received |
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| Collected For: | PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, |
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| Definition: | Documentation that the patient received antibiotics within 24 hours or the day prior to arrival and/or during this hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf). An antibiotic may be defined as any drug, such as penicillin or streptomycin, containing any quantity of any chemical substance produced by a microorganism or made synthetically (i.e., quinolones) which has the capacity to inhibit the growth of or destroy bacteria and other microorgansims. Antibiotics are used in the prevention and treatment of infectious diseases. Consider only antibiotics given via an appropriate route (SCIP-Inf: PO, IV or PN: PO, IV, IM). |
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| Suggested Data Collection Question: | Did the patient receive an antibiotic via an appropriate route (SCIP-Inf: PO, IV) (PN: PO, IV, IM)? |
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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: |
1 Antibiotic received only within 24 hours or the day prior to arrival and not during hospital stay.
2 Antibiotic received within 24 hours or the day prior to arrival and during hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf).
3 Antibiotic received only during hospital stay (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf).
4 Antibiotic not received (arrival through 24 hours for PN and arrival through 48 hours postop [72 hours postop for CABG or Other Cardiac Surgery] for SCIP-Inf), or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Antibiotics listed as “current” or “home meds,” etc., should be inferred as taken within 24 hours or the day prior to arrival, unless there is documentation they were not taken within the last 24 hours.
- When the medical record contains documentation of medication administration such as “started on antibiotics two days ago” or “patient given antibiotics two days ago” and the antibiotic is not listed as a current medication and there is NO documentation to suggest the medication was taken within 24 hours or the day prior to arrival, do not use this documentation to select Allowable Values “1” or “2.” There is not enough supporting documentation to indicate that the patient received antibiotics within 24 hours prior to arrival. However, if there is other documentation to suggest antibiotics were taken within 24 hours or the day prior to arrival, such as, “maintained on Levaquin”, or “patient has been taking Rocephin for the last 5 days”, this will be appropriate for antibiotics prior to arrival.
- Only consider antibiotics listed in Appendix C, Table 2.1. Do not consider any medications other than antibiotics (i.e., antivirals, antifungals, antituberculins, antiprotozoans, etc.)
- Only collect antibiotics given via an appropriate route (SCIP-Inf: PO, IV or PN: PO, IV, IM).
- In order to ascertain whether antibiotics were administered during this hospitalization, please see the Notes for Abstraction for the data element, Antibiotic Name.
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| Suggested Data Sources: |
- Emergency department record
- History and physical
- Nursing notes
- Nursing admission assessment
- Progress notes
- Medication administration record (MAR)
- Any source documenting antibiotic administration
- EMT/Ambulance records
- ICU Flowsheet
- IV Flowsheet
- Medication reconciliation form
- Perfusion Record
- Physician admitting notes
For SCIP-Inf, in addition to the above suggested data sources, the following may also be utilized:
- Consultation notes
- Pre-anesthesia assessment
- Preoperative assessments
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Include any antibiotics given:
Intravenous:
- Bolus
- Infusion
- IV
- I.V.
- IVPB
- IV piggyback
- Parenteral
- Perfusion
PO/NG/PEG tube:
- Any kind of feeding tube (e.g., percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy, gastrostomy tube)
- By mouth
- Gastric tube
- G-tube
- Jejunostomy
- J-tube
- Nasogastric tube
- PO
- P.O.
For PN, in addition to the above routes, also include any antibiotics given:
Intramuscular:
Refer to Appendix C, Table 2.1 for a comprehensive list of Antimicrobial Medications.
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- Abdominal irrigation
- Chest irrigation
- Eardrops
- Enema/rectally
- Eyedrops
- Inhalation
- Intracoronary
- Joint irrigation
- Mixed in cement
- Mouthwash
- Nasal sprays
- Peritoneal dialysate (antibiotic added to)
- Peritoneal irrigation
- Swish and spit
- Swish and swallow (S/S)
- Topical antibiotics
- Troches
- Vaginal administration
- Wound irrigation
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Antibiotic Received
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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