Pneumonia (PN)

Set Measures

Set Measure ID	Measure Short Name
PN-2	Pneumococcal Vaccination
PN-3a	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
PN-3b	Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
PN-4	Adult Smoking Cessation Advice/Counseling
PN-5	Antibiotic Timing (Median)
PN-5a	Initial Antibiotic Received Within 8 Hours of Hospital Arrival - RETIRED
PN-5b	Initial Antibiotic Received Within 4 Hours of Hospital Arrival
PN-5c	Initial Antibiotic Received Within 6 Hours of Hospital Arrival (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
PN-6	Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
PN-7	Influenza Vaccination

General Data Elements

Element Name	Collected For
Birthdate	All Records,
Discharge Date	All Records, (used in algorithm for AMI-1, AMI-6, PN-1, PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7, PR-2, SCIP-Inf-4, SCIP-VTE-1, SCIP-VTE-2)
Discharge Status	All Records, (used in algorithm for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-6, AMI-9, AMI-T1a and AMI-T2 [CMS Optional Test Measures], CAC-3 [Joint Commission Test Measure], All HF Measures, All PN Measures, PR-2)
First Name	All Records, CMS Only,
Hispanic Ethnicity	All Records, CMS Only,
Hospital Patient Identifier	All Records, CMS Only, NOTE: Refer to the Hospital Clinical Data XML File Layout in the Transmission section of this manual.
Last Name	All Records, CMS Only,
Patient HIC#	All Records, CMS Only, Collected by CMS for patients with a Payment Source - Medicare who have a standard HIC number.
Physician 1	All Records, Optional for All Records, (CMS Optional Element)
Physician 2	All Records, Optional for All Records, (CMS Optional Element)
Point of Origin for Admission or Visit	All Records, (used in algorithm for AMI-1, AMI-6, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, PN-1, PN-3a, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b
Postal Code	All Records, CMS Only,
Race	All Records, CMS Only,

Algorithm Output Data Elements

Element Name	Collected For
Measure Category Assignment	Joint Commission Only, Calculation, Transmission, Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name	Collected For
ABG Done
Adult Smoking Counseling	PN-4,
Adult Smoking History	PN-4,
Another Suspected Source of Infection	PN-6, PN-6a, PN-6b,
Antibiotic Administration Date	PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Antibiotic Administration Route	PN-6, PN-6a, PN-6b,
Antibiotic Administration Time	PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Antibiotic Allergy	PN-6, PN-6a, PN-6b,
Antibiotic Name	PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Antibiotic Received	PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Arrival Date	PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Arrival Time	PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Blood Culture Collected	PN-3a, PN-3b,
Chest X-Ray	PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7,
Comfort Measures Only	PN-2, PN-3a, PN-3b, PN-4, PN-5, PN-5a, PN-5b, PN-5c, PN-6, PN-6a, PN-6b, PN-7,
Compromised	PN-6, PN-6a, PN-6b,
Diagnostic Uncertainty	PN-5, PN-5b, PN-5c,
Healthcare Associated PN	PN-6, PN-6a, PN-6b,
ICU Transfer or Admission Within First 24 Hours	PN-3a, PN-6, PN-6a, PN-6b,
Identified Pathogen	PN-6, PN-6a, PN-6b,
Influenza Vaccination Status	PN-7,
Initial Blood Culture Collection Date	PN-3a, PN-3b,
Initial Blood Culture Collection Time	PN-3a, PN-3b,
Pneumococcal Vaccination Status	PN-2,
Pneumonia Diagnosis: ED/Direct Admit	PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,
Pseudomonas Risk	PN-6, PN-6a, PN-6b,
Pulse Oximetry Done
Risk Factors for Drug-Resistant Pneumococcus	PN-6, PN-6b,
Transfer From Another ED	PN-3a, PN-3b, PN-5, PN-5b, PN-5c, PN-6, PN-6a, PN-6b,

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Related Materials

	Document Name
	a. Table of Contents
	a1. Introduction to the manual
	a2. Acknowledgement and Conditions of Use
	a3. Using the Specifications Manual for National Hospital Inpatient Quality Measures
	b. Introduction to the Data Dictionary and lists of all data elements
	d. Missing and Invalid Data Chapter
	e. Population and Sampling Specifications
	j. National Hospital Quality Measure Data Transmission
	j1. Transmission Alphabetical Data Dictionary
	j2. Joint Commission and CMS Data Processing Flow
	z. Appendix A - ICD-9-CM Code Tables
	z. Appendix C - Medication Tables
	z. Appendix D - Glossary of Terms
	z. Appendix E - Measure Information Form and Flowchart Definitions
	z. Appendix G - Resources
	z. Appendix H - Miscellaneous Tables

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Pneumonia (PN) Initial Patient Population

The population of the PN measure set is identified using 5 data elements:

• ICD-9-CM Principal Diagnosis Code
• ICD-9-CM Other Diagnosis Codes
• Admission Date
• Birthdate
• Discharge Date

Patients admitted to the hospital for inpatient acute care are included in the PN Initial Patient Population and are eligible to be sampled if they have:

• An ICD-9-CM Principal Diagnosis Code for PN as defined in Appendix A, Table 3.1, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days

OR

• An ICD-9-CM Principal Diagnosis Code of Septicemia or Respiratory Failure as defined in Appendix A, Table 3.2 and Table 3.3 accompanied by an ICD-9-CM Other Diagnosis Code of PN as defined in Appendix A, Table 3.1, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days

• View the PN Initial Population Algorithm

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Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Because the sample for a measure set will rarely be equal to the effective sample due to exclusions and contraindications, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual.

Quarterly Sampling

Hospitals performing quarterly sampling for PN must ensure that its Initial Patient Population and effective sample size meet the following conditions:

• The effective quarterly sample size for PN is at least 35 cases per quarter; and
• The required quarterly sample size is at least 20% of the Initial Patient Population for the quarter.

Quarterly Sample Size
Based on Initial Patient Population for the PN Measure Set

Hospital's Measures
Average Quarterly Initial Patient Population “N”	Minimum Required Sample Size “n”
> 1200	241
301 - 1200	20% of the Initial Patient Population
60 - 300	60
< 60	No sampling; 100% of the Initial Patient Population is required

Monthly Sampling

Hospitals performing monthly sampling for PN must ensure that its Initial Patient Population and effective sample size meet the following conditions:

• The effective monthly sample size for PN is at least 12 cases per month; and
• The required monthly sample size is at least 20% of the Initial Patient Population for the month.

Monthly Sample Size
Based on Initial Patient Population for the PN Measure Set

Hospital's Measures
Average Monthly Initial Patient Population “N”	Minimum Required Sample Size “n”
> 400	81
101 – 400	20% of the Initial Patient Population
20 – 100	20
< 20	No sampling; 100% of the Initial Patient Population is required

Sample Size Examples

• Quarterly sampling:
  • A hospital’s PN Initial Patient Population size is 171 PN discharges during the fourth quarter. The required sample size is 60 cases.
  • A hospital’s PN Initial Patient Population size is 1,199 patients during the third quarter. The calculated sample size is 20% of the patient population or 240 cases for the quarter (twenty percent of 1,199 equals 239.8 rounded to the next highest whole number = 240).
• Monthly sampling
  • A hospital’s PN Initial Patient Population size is 800 PN discharges during January. Twenty percent of 800 equals 160 pneumonia patients -- which exceeds the maximum monthly sample size condition (i.e., 81); thus, the required sample size would be at least 81 pneumonia patients for that month.
  • A hospital’s PN Initial Patient Population size is 399 patients during July. The required sample size is 20% of the patient population or 80 cases for the month (twenty percent of 399 equals 79.8 rounded to the next highest whole number = 80).