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Disclaimer

In the Downloads section, the ‘Prior Submission’ file reflects the most recent measure submission to the former CBE. This file is provided for transparency. For any questions or clarification, please contact the designated measure steward.

PC-04 Health Care-Associated Bloodstream Infections in Newborns

CBE ID
1731
Endorsement Status
1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
1.6 Measure Description

This measure assesses the number of staphylococcal and gram negative septicemias or bacteremias in high-risk newborns. This measure is a part of a set of five nationally implemented measures that address perinatal care (PC-01: Elective Delivery, PC-02: Cesarean Birth, PC-03: Antenatal Steroids, PC-05: Exclusive Breast Milk Feeding; Beginning 1/1/2019 PC-06 Unexpected Complications in Term Newborns will be added).

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      No
      1.8 Level of Analysis
      1.9 Care Setting
      1.14 Numerator

      The outcome being measured is: Newborns with septicemia or bacteremia with ICD-10-CM Other Diagnosis Codes for newborn septicemia or bacteremia as defined in Appendix A, Table 11.10 with a Bloodstream Infection Confirmed OR ICD- 10-CM Other Diagnosis Codes for sepsis as defined in Appendix A, Table 11.10.1 with a Bloodstream Infection Confirmed.

      1.15 Denominator

      The outcome target population being measured is: Liveborn newborns with ICD-10-CM Other Diagnosis Codes for birth weight between 500 and 1499g as defined in Appendix A, Table 11.12, 11.13 or 11.14 OR Birth Weight between 500 and 1499g OR ICD-10-CM Other Diagnosis Codes for birth weight = > 1500g as defined in Appendix A, Table 11.15 or 11.16 OR Birth Weight = > 1500g who experienced one or more of the following:
      o Experienced death
      o ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for major surgery as defined in Appendix A, Table 11.18
      o ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for mechanical ventilation as defined in Appendix A, Table 11.19
      o Transferred in from another acute care hospital or health care setting within 2 days of birth.

      Exclusions

      • ICD-10-CM Principal Diagnosis Code for septicemias or bacteremias as defined in Appendix A, Table 11.10.2
      • ICD-10-CM Other Diagnosis Codes for septicemias or bacteremias as defined in Appendix A, Table 11.10.2 or ICD-10-CM Principal or Other Diagnosis Codes for newborn septicemia or bacteremia as defined in Appendix A, Table 11.10 with a Bloodstream Infection Present on Admission
      • ICD-10-CM Other Diagnosis Codes for birth weight < 500g as defined in Appendix A, Table 11.20 OR Birth Weight < 500g
      • Length of Stay < 2 days

      Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Perinatal and Women's Health Spring Cycle 2020
      Initial Endorsement
      Last Updated
      Removal Date
      Steward Organization
      The Joint Commission
      Steward POC email
      Steward Organization Copyright

      No royalty or use fee is required for copying or reprinting this manual, but the following are required as a condition of usage: 1) disclosure that the Specifications Manual is periodically updated, and that the version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified the version to be up-to-date and affirms that, and 2) users participating in Joint Commission accreditation, including ORYX® vendors, are required to update their software and associated documentation based on the published manual production timelines.

              Risk Adjustment
                Use
                Planned Use
                6.1.2 Current or Planned Use(s)
                  Public Comments