Introduction
Pathway: Community Acquired Pneumonia (CAP)
Document Publication Date: 01/11/2015
Applicable to: November 2015 discharge patients onwards
This document is designed to assist users in the completion of Assure questions for the Community Acquired Pneumonia pathway.
It is advisable that users consult this document to view detailed guidance on answering Assure questions to ensure the answers provided are accurate and in accordance with the audit criteria.
Further support is available on the Wiki including detailed measure information documents and a list of Frequently Asked Questions (FAQs).
Users have the ability to download the document to their PC should they wish to do so. However, it is the responsibility of the user to ensure that they have the latest version of the Answer Guidance document as published within the Help Section of Assure.
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Relevant to Measure | All CAP Measures |
MDE ID | CLINICAL_TRIAL_CAP |
Assure Question Definition | Documentation within the medical record that the patient was involved in a clinical trial during this hospital stay directly affecting Community Acquired Pneumonia measures. |
Answer Guidance | Clinical trials are organised studies to provide large bodies of clinical data for statistically valid evaluation or treatment. These studies are usually rigorously controlled tests of new drugs, invasive medical devices or therapies on human subjects.
This question is used to exclude patients that are involved in a clinical trial during this hospital stay which is relevant to the Community Acquired Pneumonia measure set for this admission.
Consider the patient involved in a clinical trial if documentation indicates: - The patient was newly enrolled in a clinical trial during the hospital stay.
- The patient was enrolled in a clinical trial prior to arrival and continued active participation in that clinical trial during this hospital stay.
To answer "Yes" to this question, there must be formal documentation (trial protocol or patient consent form) in the medical record that the patient was involved in a clinical trial designed to enrol patients with the condition specified in the applicable measure set.
Example:
The patient admitted with pneumonia was previously enrolled in an outpatient clinical trial for pneumonia. After admission to the hospital, the patient continued to take the medication for the trial, as documented on the trial protocol. Select "Yes".
If it is not clear which study population that the clinical trial is enrolling, select "No". Assumptions should not be made if it is not specified.
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Acceptable Documentation Source | ONLY ACCEPTABLE SOURCES: - Clinical Trial Protocol
- Consent forms for clinical trial
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient was involved in a clinical trial during this hospital stay which is relevant to the Community Acquired Pneumonia measure set. |
No: | There is no documentation within the medical record that the patient was involved in a clinical trial during this hospital stay relevant to the Community Acquired Pneumonia measure set, or it is unable to be determined from the medical record documentation. |
Unanswered: | No answer has been provided for this question |
Terminology used to answer this question | Applicable terminology: | - |
Non-applicable terminology: | - |
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Relevant to Measure | All CAP Measures |
MDE ID | TRANSFER_FROM_ANOTHER_TRUST_AE_CAP |
Assure Question Definition | There is documentation within the medical record that the patient was received as a transfer from the Accident & Emergency department of a hospital within another trust. |
Answer Guidance | Accident and emergency department of another Trust includes both A&E department AND observation bed/unit stays at that Trust. |
Acceptable Documentation Source | - Admission notes
- Accident and emergency notes
- Transfer notes
- Ambulance service notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient was received as a transfer from A&E department of another trust. |
No: | There is no documentation within the medical record that the patient was received as a transfer from the A&E department of another trust or unable to determine from medical record documentation.. |
Unanswered: | No answer has been provided for this question |
Terminology used to answer this question | Applicable terminology: | - |
Non-applicable terminology: | - |
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Q9. Pulse oximetry/arterial blood gas analysis date/time on arrival?
Relevant to Measure | CAP-2 |
MDE ID | PO_ABG_DATETIME_CAP |
Assure Question Definition | The documented day, month, and year that the patient received pulse oximetry or arterial blood gas analysis on arrival (Date).
The documented time (24 hour clock) that the received pulse oximetry or arterial blood gas analysis on arrival. (Time) |
Answer Guidance | If the date/time of pulse oximetry or arterial blood gas analysis on arrival is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples: - Documentation within the medical record indicates the Arrival Date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the Arrival Date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "UTD."
- Documentation within the medical record indicates the Arrival Time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD."
- Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the Arrival Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."
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Acceptable Documentation Source | ONLY ACCEPTABLE SOURCES: - Accident and emergency notes
- Medical assessment unit notes
- Admission notes
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DATE
Question Allowable Answers | DD | Day (01 - 31) |
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Unknown | Unknown |
TIME
Question Allowable Answers | HH | Hour (00 - 23) |
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24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon: If the time is in the a.m., conversion is not |
requiredIf required If the time is in the p.m., add 12 to the clock time hour
Examples: | Midnight - 00:00 | Noon - 12:00 | | 5:31am - 05:31 | 5:31pm - 17:31 | | 11:59am - 11:59 | 11:59pm - 23:59 |
If documented time is 11:59pm on 1/1/2014 enter 11.59 01/01/2016
If documented time is midnight enter the following date: 00:00 02/01/2016 |
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| Terminology used to answer this question | Applicable terminology | - |
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| Non-applicable terminology | - |
Q10. Is there documentation within the clinical record that the patient was clinically indicated to receive oxygen, following initial ocxygen assessments on arrival?
Relevant to Measure | CAP-3 | |
MDE ID | O2_CI_CAP | |
Assure Question Definition | Documentation within the medical record that the patient was clinically indicated to receive oxygen, following initial oxygen assessments on arrival | |
Answer Guidance | Pulse oximetry is a non-invasive test to measure the percentage of oxygen saturation of haemoglobin in the patient's arterial circulation. A pulse oximeter may be clipped to a patient's finger to obtain oxygen saturation.
ABG is an analysis of the pH, concentration and pressure of oxygen, carbon dioxide and hydrogen ions in the blood. It is used to assess acid-base balance and ventilatory status in a wide range of conditions. Arterial blood gas (ABG) determination is performed on arterial, rather than venous, blood.
If there is documentation within the medical record that the patient was clinically indicated to receive oxygen, following initial oxygen assessments on arrival select 'Yes'. If there is documentation within the medical record that the patient was not clinically indicated to receive oxygen, following initial oxygen assessments on arrival select 'No'.
Patients with oxygen saturation levels of 95% and above can be marked as not clinically indicated to receive oxygen, therefore in this case select 'No'. | |
Acceptable Documentation Source Accident | - Accident and emergency notes
| Admission | Medical - Medical assessment unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the clinical record that the patient was clinically indicated to receive oxygen, following initial oxygen assessments on arrival. |
No: | There is documentation within the clinical record that the patient was not clinically indicated to receive oxygen, following initial oxygen assessments on arrival.
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Unanswered: | No answer has been provided for this question |
Terminology used to answer this question | Applicable terminology: | - O2 sat
- Pulse oximetry
- Pulse ox
- SaO2
- SPO2
- ABG
- Arterial blood gas results
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Non-applicable terminology: | - |
Q11. If oxygen was clinically indicated on arrival, please detail the given date/time?
Relevant to Measure | CAP-3 | |
MDE ID | O2_GIVEN_DATETIME_CAP | |
Assure Question Definition | The documented day, month, and year that oxygen was given on arrival (Date).
The documented time (24 hour clock) that oxygen was given on arrival. (Time) | |
Answer Guidance | If the date/time of oxygen being given on arrival is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples: - Documentation within the medical record indicates the Arrival Date was 42-03-2007. No other documentation in the list of ONLY Acceptable Sources provides a valid date. Since the Arrival Date is outside of the range listed in the Allowable Values for "Day", it is not a valid date and the abstractor should select "UTD."
- Documentation within the medical record indicates the Arrival Time was 3300. No other documentation in the list of ONLY Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD."
- Patient expires on 12-02-2007 and all documentation within the ONLY Acceptable Sources indicates the Arrival Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."
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Acceptable Documentation Source | ONLY ACCEPTABLE SOURCES: - Accident and emergency notes
- Medical assessment unit notes
- Admission notes
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DATE
Question Allowable Answers | DD | Day (01 - 31) |
| MM | Month (01 - 12) |
| YYYY | Year (2000 - 9999) |
| Unknown | Unknown |
TIME
Question Allowable Answers | HH | Hour (00 - 23) |
| MM | Minutes (00 - 59) |
| Unknown | Unknown |
| 24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon: If the time is in the a.m., conversion is not requiredIf the time is in the p.m., add 12 to the clock time hour
Examples: | Midnight - 00:00 | Noon - 12:00 | | 5:31am - 05:31 | 5:31pm - 17:31 | | 11:59am - 11:59 | 11:59pm - 23:59 |
If documented time is 11:59pm on 1/1/2014 enter 11.59 01/01/2016
If documented time is midnight enter the following date: 00:00 02/01/2016 |
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| Terminology used to answer this question | Applicable terminology | - |
| Non-applicable terminology | - |
Q12. Is there documentation within the clinical record that the patient has been admitted to hospital within the last 10 days?
Relevant to Measure | CAP-4, CAP-5 |
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MDE ID | PRIOR_HOSPITALISATION_10DAYS_CAP |
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Assure Question Definition | There is documentation that the patient has been admitted to hospital within the last 10 days. |
| Answer Guidance | The intent of this question is to exclude possible nosocomial (hospital acquired) infections, i.e. the patient was discharged from an acute care facility for inpatient care to a non-acute setting (e.g. home, ICF or rehabilitation hospital), before the second admission to the same or different acute care facility |
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Acceptable Documentation Source | - Accident and emergency notes
- Admission notes
- Medical/surgical ward notes
- GP referral letter
- Hospital discharge summary
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient has been admitted to hospital within the last 10 days. |
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No: | There is documentation within the clinical record that the patient was not clinically indicated to receive oxygen, following initial oxygen assessments on arrival. |
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Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | - Recent admission date DD.MM.YYYY (within 10 days of this current admission).
- Recent stay in an acute care facility for inpatient care date DD.MM.YYYY (within 10 days of this current admission)
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Non-applicable terminology: | - Residential care
- Care home stay
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Q13. Is there documentation within the clinical record that the patient was immunocompromised (as defined by the data dictionary)?
Relevant to Measure | CAP-4, CAP-5 | |
MDE ID | IMMUNOCOMPROMISED_CAP | |
Assure Question Definition | There is documentation that the patient has been admitted to hospital within the last 10 days. | |
Answer Guidance | For the purpose of this measure immunocompromised includes 2 concepts: - There is documentation within the medical record that the patient had a condition or hospital stay, or was taking medication that may result in them being immunocompromised
- The patient has a clinical condition that could cause an impaired immune system or put the patient at a higher risk for infection.
All conditions listed in the inclusions list can be documented within the last three months OR as diagnosed for the first time during this hospital visit, with the exception of corticosteroid/prednisone therapy. Systemic corticosteroid/prednisone therapy must have occurred within the last three months prior to this hospitalisation. If there is no time frame documented in the medical record to indicate the condition has been present within the last 3 months (i.e. 'history of', etc.), select "No". A single dose does not constitute therapy. Systemic 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'. If there is documentation of chronic 'steroids', select "Yes".
EXCEPTIONS:
HIV, AIDS, Immunodeficiency syndromes and organ transplants do not require a timeframe, as once they are present they are always present. Significant neutropenia should be defined as absolute granulocyte or neutrophil count less than 1000 OR if there is Consultant (or working as part of the Consultant team) documentation of "significant" or "marked" neutropenia, select "Yes". |
Acceptable Documentation Source | - Accident and emergency notes
- Admission notes
- GP referral letter
- Medical/surgical ward notes
- Hospital discharge summary
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation that the patient was immunocompromised. |
No: | There is no documentation that the patient was immunocompromised. | |
Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | Patients with conditions which cause problems with immune response these include:- - HIV/AIDS
- Leukaemia
- Lymphoma
- Multiple myeloma
- Long term steroid therapy
- Patients on biological therapies, cancer chemotherapy, immunosuppressive drugs for transplantation or anti- tumour necrosis factor medications for rheumatoid disease, Crohn's disease or psoriasis such as infliximab, etanercept or adalimumab
- Neutropaenia
- Primary humoral immune deficiency
- Chronic granulomatous disease
- Compliment deficiency
- Myelodysplasia
- Pancytopaenia
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Non-applicable terminology: | - Any skin cancers without documentation of chemotherapy or radiation therapy within the last three months
- Any steroid therapy that is not systemic (that is, by inhaler, eye drops, topical treatments)
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Relevant to Measure | CAP-4, CAP- | 5 5 |
MDE ID | ANOTHER_SUSPECTED_SOURCE_OF_INF_CAP | |
Assure Question Definition | There was another suspected infection in addition to pneumonia upon arrival. | |
Answer Guidance | There must be documentation of an infection/suspected infection, other than pneumonia, on arrival in order to select "Yes" for this question. Only consider infections/suspected infections that are being/will be treated by an ANTIBIOTIC listed in Appendix C, Table 2.1, that are administered via routes PO, IM or IV. There does not need to be documentation that ties the antibiotic to the infection/suspected infection, as one antibiotic may cover multiple infections. Documentation of signs or symptoms (e.g., fever, elevated white blood cells, etc) should not be considered infections unless documented as an infection or possible/suspected infection. Example:
Do not assume infection if a wound/surgical site is described as reddened, swollen and hot, as other conditions can also cause these symptoms. This question will accept both "suspected" infections and "diagnosed" infections. Examples: Upon arrival, there is Consultant documentation the patient has cellulites, select "Yes". In A&E Department, after arrival, there is Consultant documentation that she suspects the patient has a UTI, select "Yes." | |
Acceptable Documentation Source | Consultant (or working as part of the Consultant team) documentation - Accident and emergency notes
- Admission notes
- Medical assessment unit notes
- Medical/surgical ward notes
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that there was another suspected source of infection in addition to pneumonia within on arrival. | | |
No: | There is no documentation within the medical record of other suspected sources of infection on arrival or unable to determine from medical record documentation. | | |
Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | - Abscess outside of the lung
- Cellulitis
- Infected skin ulcer
- Intra-abdominal infections (e.g. cholecystitis, diverticulitis, cystitis, pyelonephritis)
- Meningitis
- Osteomyelitis or septic joint (infective arthritis)
- Prostatitis
- Urinary Tract infection
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Non-applicable terminology: | - Any other infection in the Respiratory Tract (sinusitis, laryngitis, bronchitis, COPD or other lung infections)
- Bacteremia or blood stream infections (unless there is another infection outside of the Respiratory Tract or at the time of arrival, patient has a central intravenous catheter [e.g. Hickman catheter, peripherally inserted central catheter PICC line).
- Fungal infections of the skin (dermatophytosis of nails, skin, scalp)
- Sepsis (unless there is another infection outside of the Respiratory Tract)
- Viral infections (e.g., hepatitis, herpes, HIV) unless this is a viral pneumonia.
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Q15. Is there documentation within the clinical record that the patient was already receiving antibiotics upon arrival?
Relevant to Measure | CAP-4, CAP-5 | | |
MDE ID | ALREADY_ON_ANTIBIOTIC_CAP | | |
Assure Question Definition | There is documentation within the medical record that the patient was already receiving antibiotics upon arrival. | | |
Answer Guidance | There must be documentation that the patient was detailed as already receiving antibiotics on arrival in order to select "Yes" for this question. | | |
Acceptable Documentation Source | Consultant (or working as part of the Consultant team) documentation - Accident and emergency notes
- Admission notes
- Medical assessment unit notes
- Medical/surgical ward notes
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient was already receiving antibiotics on arrival. |
No: | There is no documentation within the medical record that the patient was already receiving antibiotics on arrival. | |
Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | - |
Non-applicable terminology: | - |
Q16. Is there documentation within the clinical record that the patient refused antibiotics?
Relevant to Measure | CAP-4, CAP-5 | |
MDE ID | ANTIBIOTIC_REFUSED_CAP_Q30 | |
Assure Question Definition | There is documentation within the medical record that the patient refused antibiotics. | |
Answer Guidance | There must be documentation that the patient refused antibiotics in order to select "Yes" for this question. | |
Acceptable Documentation Source | - Accident and emergency notes
- Admission notes
- Medical assessment unit notes
- Medical/surgical ward notes
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient refused antibiotics | | |
No: | There is no documentation within the medical record that the patient refused antibiotics | | |
Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | - | | |
Non-applicable terminology: | - |
Q17. Please enter the details of the antibiotic(s) given which were specific to the patient's Community Acquired Pneumonia treatment: substance; route; date of administration; time of administration (if date and time are unable to be determined from the medical record select 'UTD'
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Note - question 17 is the antibiotic table and guidance has been split into four sections - drug, route, date of administration and time of administration. This entry is part 1 of 4.
Relevant to Measure | CAP-4, CAP-5 | |
MDE ID | ANTIBIOTIC_TABLE_CAP | |
Assure Question Definition | There is documentation within the medical record that the patient refused antibiotics. | |
Answer Guidance | There must be documentation that the patient refused antibiotics in order to select "Yes" for this question. | |
Acceptable Documentation Source | - Accident and emergency notes
- Admission notes
- Medical assessment unit notes
- Medical/surgical ward notes
- Intensive Care Unit notes
- High dependency unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient refused antibiotics | | |
No: | There is no documentation within the medical record that the patient refused antibiotics | |
| Unanswered: | No answer has been provided for this question. |
Terminology used to answer this question | Applicable terminology: | - | | |
Non-applicable terminology: | - |
Table - Antibiotics given: route
Note - question 17 is the antibiotic table and guidance has been split into four sections - drug, route, date of administration and time of administration. This entry is part 2 of 4.
Relevant to Measure | CAP-4, CAP-5 |
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MDE ID | ANTIBIOTIC_TABLE_CAP |
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Assure Question Definition | Method of administration of a dose of medication. Medications may be administered in a variety of ways depending upon how they are supplied and prescribed. |
| Answer Guidance | The measure is designed to capture the appropriate administration of appropriate antibiotics. The route of administration is appropriate if given orally or intravenously. A comprehensive list of terminology is given below. |
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Acceptable Documentation Source | - Drug prescription sheets – oral and IV
- Operative notes
- Pharmacy information
- High dependency Unit notes
- Intensive care unit notes
- Accident and Emergency Unit notes
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Question Allowable Answers
| MDE Value | Route |
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1Oral | | | | |
Terminology used to answer this question | Applicable terminology: | Include any antibiotics given:
Intravenous: - Bolus
- Infusion
- IV/I.V.
- IV piggyback/IVPB
- Parenteral
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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.
Refer to Appendix C, Table 2.1 for a comprehensive list of Antimicrobial Medications.
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Non-applicable terminology: | - Abdominal irrigation
- Chest irrigation
- Eardrops
- Enema/rectally
- Eye drops
- 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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Table - Antibiotics given: date of administration
Note - question 17 is the antibiotic table and guidance has been split into four sections - drug, route, date of administration and time of administration. This entry is part 3 of 4.
Relevant to Measure | CAP-4, CAP-5 |
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MDE ID | ANTIBIOTIC_TABLE_CAP |
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Assure Question Definition | The date (day, month and year) for which an antibiotic dose was administered.
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 microorganisms. Antibiotics are used in the prevention and treatment of infectious diseases. |
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Answer Guidance | If the date an antibiotic is administered is unable to be determined from medical record documentation, enter "UTD".
The medical record must be abstracted as documented (taken at "face value"). When the date documented is obviously in error (not a valid format/range or outside of the parameter of care [after the Discharge Date]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples: - Documentation indicates the Antibiotic Administration Date was on 42-02-2007. No other documentation in the medical record provides a valid date. Since the Antibiotic Administration Date is outside of the range listed in the Allowable Values for "Day," it is not a valid date and the abstractor should select "UTD."
- Patient expires on 12-02-2007 and documentation indicates the Antibiotic Administration Date was 12-03-2007. Other documentation in the medical record supports the date of death as being accurate. Since the Antibiotic Administration Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."
Note:
Transmission of a case with an invalid date as described above, will be rejected from Clarity Data Warehouse. Use of "UTD" for Antibiotic Administration Date allows the case to be accepted into the warehouse.
Collect only antibiotics administered via an appropriate route (Hip/Knee, CABG: PO and IV; PN: PO, IV and IM) to answer this question.
The use of "infusion time" is acceptable as antibiotic administration time when other documentation cannot be found.
If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered.
Only use "Antibiotic NOS" in the following situations: - For new antibiotics that are not yet listed in Table 2.1
- When there is documentation an antibiotic was administered but unable to identify the name. It must be apparent that the medication is an antibiotic.
Example: - On 12-2-07, the ED record contains the documentation, "Antibiotic started name illegible, 2gm, IV, 0200-JM". In the antibiotic grid, "Antibiotic NOS" would be entered for the name, IV for the route, 0200 for the time and 12-2-07 for the date. (If "Antibiotic started" had not been documented in this example, the medication could not be abstracted as an Antibiotic Received.
A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 36 hours for PN and arrival through 48 hours postop [72 hours postop for CABG and Other Cardiac Surgery] for Hip/Knee) record the antibiotic name once for each route by which it was administered.
Example: - A patient arrives at the hospital at 07:15 on 05-05-2004. Zithromax IV is administered in A&E at 09:30 on 05-05-2005. On 06-05-2004 at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax 05-05-2004, 09:30, IV and Zithromax 06-05-2004, 09:00, PO.
Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic, enter an Antibiotic Administration Route, Date and Time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilise "UTD" for the missing information.
Examples: - Do not use Consultant orders as they do not demonstrate administration of the antibiotic (in A&E department this may be used if signed/initialed by a nurse).
- In narrative documentation, only accept documentation that reflects the actual administration of the antibiotic.
The date of administration must be documented on each side of every page used as a data source. If this is not the case, utilise "UTD" for the missing date.
If an A&E department form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for A&E department documentation only. If this is not the case, utilise "UTD" for the missing date.
Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic. - First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Surgery End Time (72 hours postop for CABG or Other Cardiac Surgery).
- Second: Abstract the dose administered prior and closest to Surgical Incision Time.
Example: - Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered at 15:30 and 17:00. Abstract:
- Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
- Antibiotic B: 15:30 (first) and 17:00 (last)
Note:
This question has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery). However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable. |
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Acceptable Documentation Source | - Drug prescription sheets – oral and IV
- Operative notes
- Pharmacy information
- High dependency Unit notes
- Intensive care unit notes
- Accident and Emergency Unit notes
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Question Allowable Answers |
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UTD | Unable to Determine |
Terminology used to answer this question | Applicable terminology: | - |
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Non-applicable terminology: | - |
Table - Antibiotics given: time of administration
Note - question 17 is the antibiotic table and guidance has been split into four sections - drug, route, date of administration and time of administration. This entry is part 4 of 4.
Relevant to Measure | CAP-4, CAP-5 | | |
MDE ID | ANTIBIOTIC_TABLE_CAP | | |
Assure Question Definition | The time (24 hour clock) for which an antibiotic dose was administered. | | |
Answer Guidance | If the time an antibiotic is administered is unable to be determined from medical record documentation, enter UTD.
The medical record must be abstracted as documented (taken at "face value"). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select "UTD".
Example: - Documentation indicates the Antibiotic Administration Time was 3300. No other documentation in the medical record provides a valid time. Since the Antibiotic Administration Time is outside of the range listed in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD".
The use of "hang time" or "infusion time" is acceptable as antibiotic administration time when other documentation cannot be found.
If an antibiotic is started and the infusion is interrupted by an event such as the IV being dislodged, the tubing becoming disconnected, or the patient experiencing an allergic reaction, abstract the time the infusion was started. Similarly, if a patient vomits after an oral antibiotic is administered, abstract the time the antibiotic was administered.
If collecting the time for an antibiotic administered via infusion (IV), the Antibiotic Administration Time refers to the time the antibiotic infusion was started
A specific antibiotic is defined as having a single generic name and being administered via a single appropriate route (if trade names are used, a crosswalk is provided in Appendix C, Table 2.1). If the route of administration of an antibiotic changes during the hospital stay (arrival through 36 hours for PN and arrival through 48 hours post-op [72 hours post-op for CABG or Other Cardiac Surgery] for Hip/Knee) record the antibiotic name once for each route by which it was administered.
Example: - A patient arrives at the hospital at 07:15 on 05-05-2004. Zithromax IV is administered in A&E department at 09:30 on 05-05-2004. On 06-05-2004 at 09:00, Zithromax PO is recorded as administered on the MAR. Enter: Zithromax 05-05-2004, 09:30, IV and Zithromax 06-05-2004, 09:00, PO.
Do not abstract antibiotic administration information for a specific antibiotic from more than one data source. For EACH antibiotic name, enter an Antibiotic Administration Route, Date, time. If all information (antibiotic route, date and time) is not contained in a single data source for that specific antibiotic, utilise "UTD" for the missing information.
Example: - The signed and dated anaesthesia record contains the documentation: "Amoxicillin 1 gm at 10:50". The route is missing from this documentation. Enter "UTD" for the route in this grid entry. Do not use the operative report that contains documentation of the route to collect the missing information from the anaesthesia record.
Antibiotic administration information should be abstracted from a single source that demonstrates actual administration of the specific antibiotic.
Examples: - Do not use Consultant orders as they do not demonstrate administration of the antibiotic (in A&E department this may be used if signed/initialed by a nurse).
- In narrative documentation, only accept documentation that reflects the actual administration of the antibiotic.
The date of administration must be documented on each side of every page used as a data source. If this is not the case, utilise "UTD" for the missing date.
If an A&E department form has a stamp or sticker on each page that contains the date, this may be abstracted for the date for A&E department documentation only. If this is not the case, utilise "UTD" for the missing date.
Either a signature or initials signifying administration of the medication is required to abstract a specific antibiotic. - First: Abstract the first and last dose of each specific antibiotic administered from hospital arrival through the first 48 hours after Surgery End Time (72 hours postop for CABG or Other Cardiac Surgery).
- Second: Abstract the dose administered prior and closest to Surgical Incision Time. If two or more times are documented for the same dose, abstract the dose administered closest to Surgical Incision Time.
| ExampleExample: - Arrival time was 07:00. Surgical Incision Time was 12:00. Surgery End Time was 14:00. Antibiotic A was administered at 08:00, 10:00, 12:00, 15:30, 17:00 and 19:00. Antibiotic B was administered at 15:30 and 17:00. Abstract:
- Antibiotic A: 08:00 (first), 12:00 (dose prior and closest to Surgical Incision Time) and 19:00 (last)
- Antibiotic B: 15:30 (first) and 17:00 (last)
Note:
This question has two approaches for abstraction. The first approach allows the abstractor to collect three doses (or less) of each antibiotic administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery). However, if an abstractor chooses to abstract EACH antibiotic dose administered from hospital arrival through 48 hours postop (72 hours postop for CABG or Other Cardiac Surgery), this is acceptable. | | |
Acceptable Documentation Source | - Drug prescription sheets – oral and IV
- Operative notes
- Pharmacy information
- High dependency Unit notes
- Intensive care unit notes
- Accident and Emergency Unit notes
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Question Allowable Answers | HH | Hour (00 - 23) |
| MM | Minutes (00 - 59) |
| UTD | Unable to Determine |
| 24 hour clock – A 24-hour period from midnight to midnight using a 4-digit number of which the first two digits indicate the hour and the last two digits indicate the minute.
Converting clock time to 24 hour clock:
With the exception of Midnight and Noon:
If the time is in the am, conversion is not required
If the time is in the pm, add 12 to the clock time hour
Examples: | Midnight - 00:00 | Noon - 12:00 | | 5:31am - 05:31 | 5:31pm - 17:31 | | 11:59am - 11:59 | 11:59pm - 23:59 |
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Relevant to Measure | CAP-5 | |
MDE ID | APPROPRIATE_ANTIBIOTIC_REGIMEN_CAP | |
Assure Question Definition | Documentation within the medical record that the patient received the appropriate antibiotic regimen. Current local guidelines are used to determine if the appropriate antibiotic regime was received. | |
Answer Guidance | It is important that patients suffering pneumonia are given antibiotics which are approved and appropriate to current local guidelines. These are subject to change as a result of evolving clinical guidance and development of pathogenic resistance and newer antibiotics.
Rather than a prescribed list of medication and narrow definition of medications we accept that local clinicians may define the appropriate medications for their patients with agreed parameters. Provided that there is evidence that this local policy has been adhered to, the patient should pass this quality measure of care in pneumonia.
Consider the current local guidelines carefully making sure the appropriate drug(s) as well as the appropriate route of administration are used. | |
Acceptable Documentation Source |
- Drug prescription sheets – oral and IV
- Pharmacy information
- Medical/surgical ward notes
- High dependency Unit notes
- Intensive care unit notes
- Accident and Emergency Unit notes
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Question Allowable Answers
(An answer shaded in grey denotes this as the default answer when no other answer is provided) | Yes: | There is documentation within the medical record that the patient refused antibiotics | |
| No: | There is no documentation within the medical record that the patient refused antibiotics | |
| Unanswered: | No answer has been provided for this question. | |
Terminology used to answer this question | Applicable terminology: | - | |
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