Discharges with healthcare-associated bloodstream infection per 1,000 discharges for newborns and outborns with birth weight of 500 grams or more but less than 1,500 grams; with gestational age between 24 and 30 weeks; or with birth weight of 1,500 grams or more and death, an operating room procedure, mechanical ventilation, or transferring from another hospital within two days of birth. Excludes discharges with a length of stay less than 3 days and discharges with a principal diagnosis of sepsis, or bacteremia, or newborn bacteremia.
Measure Specs
General Information
Numerator
Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with either:
• any secondary ICD-10-CM diagnosis codes for newborn sepsis (BSI5DX*), or
• any secondary ICD-10-CM diagnosis codes for newborn septicemia or bacteremia codes requiring a separate organism code (BSI2DX*) and any secondary ICD-10-CM diagnosis codes for staphylococcal or Gram-negative bacterial infection (BSI3DX*)
Denominator
All newborns and outborns (Appendix I) with either:
• a birth weight of 500 to 1,499 grams (Birth Weight Categories 2, 3, 4 and 5) (Appendix L)
• any-listed ICD-10-CM diagnosis codes for gestational age between 24 and 30 weeks; (GESTCAT*)
• a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and death (DISP=20)
• a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and any-listed ICD-10-PCS procedure codes for operating room procedure (Appendix A)
• a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and any-listed ICD-10-PCS procedure codes for mechanical ventilation (MECHVCD*)
• a birth weight greater than or equal to 1,500 grams (Birth Weight Category 6, 7, or 8) and transferring from another health care facility within two days of birth (ATYPE = 4 and POINTOFORIGINUB04 = 6)
Exclusions
Exclude cases:
• with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) for sepsis or bacteremia (BSI4DX*), among patients otherwise qualifying for numerator.
• with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission†) for staphylococcal or Gram-negative bacterial infection (BSI3DX*), among patients otherwise qualifying for numerator.
• with birth weight less than 500 grams (Birth Weight Category 1) (Appendix L)
• with length of stay less than 3 days
• with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)
Measure Record
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