Release Notes:
Data Element
Version 2010B
| Data Element Name: | Pseudomonas Risk |
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| Collected For: | PN-6, PN-6a, PN-6b, |
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| Definition: | Risk of pseudomonas is defined as any patient who has documentation of one of the following by the physician/advanced practice nurse/physician assistant (physician/APN/PA):
- Bronchiectasis documented as a possible consideration. Bronchiectasis is defined as chronic dilatation of a bronchus or bronchi, with a secondary infection that usually involves the lower portion of the lung. Dilatation may be in an isolated segment or spread throughout the bronchi.
- Physician/APN/PA documented pseudomonal risk
Structural lung disease AND documented history of repeated antibiotics or chronic systemic corticosteroid use.
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| Suggested Data Collection Question: | Does the patient have risk of pseudomonas? |
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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) The patient has risk of pseudomonas as indicated by documentation of one or more of the above conditions.
N (No) The patient has no risk of pseudomonas as indicated by none of the above conditions being documented in the medical record or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Repeated antibiotics and/or chronic systemic corticosteriod can be for any reason. It does not have to be linked to the structural lung disease. Example: Patient is taking chronic steroids for Lupus and they also have COPD.”
- For the purposes of this data element, structural lung disease includes:
- Chronic Bronchitis
- COPD
- Emphysema
- Interstitial lung disease
- Pulmonary Fibrosis
- Restrictive lung disease
- One time use or one course of antibiotics or systemic corticosteroids is not considered chronic.
- Corticosteroids listed as “home meds” or “current meds”, are considered “chronic”, unless there is documentation it is a one time course, or if it is listed as ‘PRN’.
- “Repeated antibiotics” are defined as documentation of multiple “rounds” or “courses” of antibiotics.
- If there is documentation of chronic ‘steroids’, select “Yes.”
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Admitting physician orders
- Admitting progress notes
- Physician admission note
EXCEPTION:
“Home meds” or “current meds” do not require documentation by a physician/APN/PA; other data sources may be used.
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Bronchiectasis
- Need to evaluate for
- Possible
- Probable
- Questionable
- Rule/out bronchiectasis
Pseudomonal Risk:
- Pseudomonal risk
- Structural lung disease with multiple rounds of antibiotics
- Structural lung disease with chronic systemic corticosteroid use
- Structural lung disease with long-term systemic corticosteroid use
Refer to Appendix C, Table 2.15 for a comprehensive list of Systemic Corticosteroids.
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Bronchiectasis
- Doubt bronchiectasis
- Respiratory problems without mention of bronchiectasis
Pseudomonal Risk
- Structural lung disease with no documentation of a history of repeated antibiotic use or chronic systemic corticosteroid use.
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Pseudomonas Risk
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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